Unless marked changes are made to the HIV workforce, the Ending the HIV Epidemic in the US (EHE) 2030 goals are unattainable, said Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC, PMHNP-BC, FAAN, at the Association of Nurses in AIDS Care (ANAC) annual meeting held November 17 to 19, 2022, in Tampa, Florida. He was met with a standing ovation following his presentation on reimagining the HIV workforce by integrating nurses and other non-specialists into the care team.
While the EHE 2030 goal is to reduce the number of new HIV infections to fewer than 3000 per year, the number of new cases was 34,800 in 2019 and only a 12% decrease in new infections was found between 2010 and 2019. Marked increases in new infection rates of 95% and 67% occurred among young Black and Latino men who have sex with men (MSM) aged 25 to 34 years, respectively, since 2010.
“If we continue to do what we have been doing for the past 10 years we are not going to reach the goal,” said Dr Guilamo-Ramos, who is dean of the Duke University School of Nursing and Vice Chancellor for Nursing Affairs. His reimagined workforce places nurses at the forefront of HIV prevention and care (Table). However, this paradigm shift will take considerable advocacy and legislative change, he said.
Table. Recommendations for a Reimaged HIV Workforce
|Remove regulatory barriers that place restrictions on practice at the highest level of training and licensure for advanced practice providers|
|Ensure CMS offers reimbursement for decentralized, differentiated, and team-based whole-person HIV prevention and care services|
|Support a shift toward education and training for the future health care workforce that emphasizes key competencies of team-based, whole-person HIV care as well as training for those not pursuing full-time HIV work. Increase funding for specialized HIV training programs (eg, via GME and GNE)|
|Invest in infrastructure development for delivery of decentralized, differentiated HIV prevention and care (eg, pharmacy-based delivery of services) and develop infrastructure to support nonexpert workforce|
|Allocate funding to HIV-specific demonstration projects designed to mitigate the specific mechanisms of SDOH and foster multilevel resilience (eg, via Medicaid Section 1115)|
Source: Guilamo-Ramos V.
The reimagined HIV workforce includes a team-based model of whole-person care that includes nurses, PAs, social workers/behavioral counselors, pharmacists, and dentists as well as physicians in linkage to care and prevention services for patients at risk for and living with HIV. This broader definition of the HIV workforce would markedly increase the number of qualified HIV care providers from the current 4400, Dr Guilamo-Ramos said. Much of this increase would come from the pool of about 4 million nurses in the US. However, state-level regulatory restrictions that prevent nurses from practicing to the highest level of their competency, training, and licensure would need to be lifted, he said.
“We are not asking for an increase in our scope of practice, we are asking to be allowed to practice consistent with our competencies, our license, and our education,” Dr Guilamo-Ramos said. “There are 50 plus years of data that care provided by NPs and PAs is comparable within areas of specialization to that of physicians and yet much of the rhetoric about safety and quality of care being less than is simply is not true.”
Nurse-delivered primary care results in comparable patient outcomes relative to physician-delivered care, including HIV treatment, he explained. Also, data suggest that advanced practice registered nurses (APRNs) and PAs who are aware of pre-exposure prophylaxis (PrEP) are approximately 50% more likely to prescribe PrEP than physicians.
Pharmacists also can play a greater role in expanding access to PrEP. In California, Senate Bill 159 authorizes pharmacists to dispense PrEP and PEP without a prescription, permitting them to administer 30 to 60 days of the drugs after testing and counseling.
Paradigm Shift for HIV Care
A strong HIV workforce is central to the paradigm shift that Dr Guilamo-Ramos is calling for. The National HIV/AIDS Strategy Implementation Plan needs to address 3 areas of workforce challenges for achieving EHE 2030 goals: scale, reach, and effectiveness.
In terms of scale, a disconnect between the HIV workforce capacity and demand exists with the workforce supply expected to decrease by 10% while demand is forecasted to increase by 14%. Increased numbers of Latino and Black health care professionals, in particular, are needed as these practitioners are underrepresented in the HIV workforce, Dr Guilamo-Ramos said.
In terms of reach, effective tools for HIV prevention/treatment exist, but inadequate reach of the systems for delivery of these effective tools remains common, Guilamo-Ramos noted. From 2018 to 2019, 136 high HIV transmission clusters were reported across 19 US states. In 11 out of 19 states (58%), Latinos were overrepresented among people in high transmission clusters.
These clusters “represent system failures,” Dr Guilamo-Ramos said. “I don’t want anyone to think that these are about individuals who are engaged in risky behavior. This represents our inability as a country to best align our HIV prevention and treatment in those geographic hot spots where these clusters continue to grow.”
Discrimination and stigma can limit the reach of these effective tools. Recent findings published in MMWR show sobering rates of discrimination and stigma among Latino patients, with nearly 1 in 4 (23%) of this population reporting health care discrimination, Dr Guilamo-Ramos said. The most common form of discrimination (62% of Latinos reporting discrimination) was feeling that a doctor or nurse was not listening to them. Fear of disclosing HIV status was also commonly reported.
Inadequate PrEP Coverage Found Among Latinos At Risk of HIV Infection
Latino individuals represent a key population for EHE to succeed, he said. Latino individuals are the largest and youngest minority population in the US and this population is expected to nearly double by 2060. Approximately 1 in 3 people in need of HIV prevention services in 2060 will be of Latino ethnicity. However, coverage of preventive strategies is inadequate among Latinos, with only 13.6% of the 312,820 Latino individuals with indications for PrEP in 2022 being prescribed this regimen in the first quarter of 2022, according to CDC data.
“We have got to do something to change that and ANAC is the group to do it,” Dr Guilamo-Ramos said. Nobody is going to do it for us. We have to speak to our colleagues who are non-ANAC members, including those with a low volume of HIV cases, to make sure patients are experiencing a setting that is welcoming.”
Increased effectiveness of HIV service delivery systems is also needed. In the Latino community, nearly 1 in 5 patients with HIV are not linked to care within 30 days of diagnosis and nearly 1 in 3 did not achieve viral suppression within 6 months of diagnosis.
Dr Guilamo-Ramos concluded that it is time to stop describing social determinants of health and to start thinking about the negative pathways that are shaping that negative outcome. Duke University School of Nursing has created a new framework for mitigating harmful social determinants of health through clinical practice and nursing science. The program will launch shortly and will be available here.
A webinar series on providing Culturally Appropriate Engagement and Service Delivery with Latino/as to Enhance Linkage and Retention to HIV Primary Care led by Dr Guilamo-Ramos was recently released at: https://healthandhousingconsortium.org/cewebinarseries-html/
Visit Clinical Advisor’s meetings section for more coverage of ANAC 2022.
Guilamo-Ramos. Reimagining the role of the HIV workforce in ending the HIV epidemic. Presented at: ANAC2022; November 17-19, 2022; Tampa, FL.