Ready or Not: HIV Patients Arrive in Primary Care

March 2017Andrew Schwartz

When Irene Ritterman (MS ’15) accepted a temporary position as a family nurse practitioner (FNP) at LifeLong Medical Care in downtown Oakland – which is part of a group of health centers that provide health and social services to underserved people across the life span – she felt well prepared to manage the clinic’s patients with human immunodeficiency virus (HIV) infection or those at risk for the condition.

Irene Ritterman Before entering the UC San Francisco School of Nursing Master’s Entry Program in Nursing, Ritterman had helped conduct HIV-related research projects in France, Mexico and the United States. During her master’s training to become an FNP, she did extra coursework to complete the School’s HIV specialty training and spent a year training at the UCSF 360 Wellness Center, which serves patients with HIV. She later completed the UCSF Global Health Nursing Fellowship, which included time at Hinche Hospital in Haiti, where Ritterman estimates as many as half of the patients on the internal medicine ward – where Ritterman spent most of her time – were HIV-positive.

“I had training and experience, which prepared me to work with HIV patients, especially because I had access to [a specialty consult],” says Ritterman of her time at LifeLong. Her colleagues recognized her experience. She had at least one HIV patient transferred to her care, because another NP felt uncomfortable initiating antiretroviral therapy (ART) for a patient who wanted to stay at the downtown Oakland clinic because of limited access to transportation to LifeLong’s HIV specialist.

“I understand why some who didn’t do specialty training or who did a clinical rotation where they didn’t see many HIV patients might feel intimidated by offering this type of care,” says Ritterman. “Hopefully, their education offered some awareness of things to look out for and what resources exist, so they can make a good decision about whether to transfer care or handle it themselves.”

A Changing HIV Landscape

That hope informs a growing, nationwide effort to address HIV in primary care, driven by a number of factors. First, many in the first generation of HIV specialists are retiring, and the pipeline to replace them is shrinking.

Perhaps more significantly, HIV has become a manageable chronic illness thanks to increasingly effective, less difficult-to-administer ARTs. Many patients now reach their normal life spans and, so, also face many of the chronic illnesses that typically accompany aging, from heart disease through diabetes, hearing and vision problems and problems with memory and cognition. In our health care system, such illnesses are often the province of primary care.

UCSF has been at the forefront of treating HIV since the infection first appeared and, unsurprisingly, is among those taking the lead in preparing primary care providers to care for these patients. This includes the UCSF School of Nursing, which is in the fourth year of a five-year Health Resources and Services Administration (HRSA)-funded training grant aimed at preparing an NP workforce to provide comprehensive primary care for people living with HIV or at risk for acquiring HIV.

Creating an HIV Curriculum for Primary Care Programs

Faculty members Carmen Portillo and Suzan Stringari-Murray have worked with clinical faculty members Erica Monasterio and Kellie Freeborn and former faculty member Christopher Fox of the FNP and Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP) programs – as well as with HRSA – to integrate HIV/AIDS competencies into the NP curricula. The hope is that the HIV content will prepare NP graduates to evaluate and treat patients with HIV in the same way they would handle other chronic illnesses. A subset of students chose to do additional coursework on HIV in the specialty program the School has offered since 2004.

“With input from HIV NP experts locally and outside the Bay Area, we’ve developed a set of competencies to guide curriculum development,” says Stringari-Murray. “The challenge of offering an NP HIV primary care curriculum is that there are frequent updates about new medications [and new formulations] as well as changes in treatment guidelines, which require ongoing revisions to several courses. Also, with improved survival due to ART, risk factor modification is more of an imperative, both for the prevention of HIV and to improve health outcomes for patients who are aging and have multiple chronic conditions in addition to their HIV.”

Understanding Vulnerable Populations

Carmen Portillo Despite these challenges, over the past four years, more than 80 students have moved through the curriculum, says Portillo, adding that, “Pre- and post-tests about HIV have shown we have really moved the needle on knowledge and attitudes, particularly on working with vulnerable and stigmatized populations.”

That’s critical, says Stringari-Murray, because NPs need to understand how to reflect on their own personal attitudes and beliefs about HIV that could interfere with the delivery of quality care for a vulnerable population with complex medical and psychosocial challenges.

“We certainly need to understand the impact HIV has on chronic conditions and how ARTs might affect chronic disease management, but at this point, the recommendations for managing chronic conditions are not very different for HIV-infected individuals,” she says. “What is different is that many HIV patients are underserved, have difficulty accessing care and experience significant health disparities, so clinicians need to know how to work with this population, including connecting them with wraparound services like transportation, housing and ART adherence management.”

It is something for which NPs seem ideally suited, says UCSF family physician Ronald Goldschmidt, who directs the Clinician Consultation Center (CCC) at UCSF, a nationwide, online and phone-based consultation service, which, according to its website, “provides clinicians of all experience levels prompt, expert responses to questions about managing HIV/AIDS, perinatal HIV, pre-exposure prophylaxis, and bloodborne pathogen exposures.”

“Advanced practice nurses may have a very large role in working with these patients because they have tremendous strengths in communication and in understanding the whole patient,” says Goldschmidt.

Yet he is quick to note that all of primary care must learn to adapt. He and Carolyn Chu, the CCC’s clinical director, recently contributed an editorial to American Family Physician in which they argue that given the confluence of factors pushing HIV patients and those at risk toward primary care, “The major challenge, therefore, is … to create a framework that allows all primary care clinicians to provide the best possible care for their patients living with HIV infection.”

They lay out four important elements. First, clarify that primary care providers are not expected to manage ART or HIV complications without consultation. Second, understand that consultation or co-management can take many forms, including making use of telemedicine and services like the CCC. Third, primary care clinicians should have ready access to up-to-date clinical guidelines. And fourth, selected HIV performance measures should be embedded in practices via electronic medical records (EMRs) to both remind clinicians and inform their quality improvement efforts.

Changing the Cultures of HIV and Primary Care

Suzan Stringari-Murray Such an approach represents a dramatic cultural change, both for those who have been working with the HIV patient population for decades and for primary care clinicians. “When this epidemic first started out, patients were seen by infectious disease specialists,” says Stringari-Murray.

“Then about 6 years ago, with recognition of the idea of a medical home, [many in the field] recognized that for HIV clinics to continue to succeed, they had to better meet the standards of medical homes,” says Goldschmidt. “Things like breast cancer screening, Pap smears, colon cancer screening and immunizations were introduced into HIV practices – and programs grew to teach those things throughout HIV clinics.”

It also became important for these clinics to understand best practices for older adults with HIV. Stringari-Murray notes that in San Francisco more than half of those with HIV are over the age of 50. A recent article in the San Francisco Chronicle highlighted a new geriatric clinic at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center’s famous Ward 86, which was the first HIV/AIDS clinic in the U.S.

In response to concerns about aging patients with multiple chronic conditions, some HIV specialty clinics began to hire primary care providers to provide comprehensive primary care, while some primary care practices began to integrate HIV care into their practices as the ART regimens became simpler to understand and administer. When the Affordable Care Act (ACA) promoted the idea that most patients should have a primary care medical home and enabled many more people to afford health insurance, some of the country’s half million HIV patients – defined as those engaged in care – migrated away from the specialty clinics and into primary care, says Goldschmidt.

Not everyone was immediately excited by the change. “These are often the hardest patients to treat, with a lot of mental health, substance use and trauma-related history – as well as widespread mistrust of the health care system,” says Stringari-Murray, who has spent decades delivering care to these patients. “These patients can be overwhelming for primary care practices, even before you add HIV management.”

That, in a nutshell, is the challenge that the School’s faculty has faced as they’ve worked to integrate HIV into primary care curricula. Some of the discussions about vulnerable populations were already there, of course, but without an HIV treatment sensibility. In addition, it’s important to find clinical placements that will give students real experience with HIV care. In that regard, San Francisco has a bit of an advantage, with a large HIV-infected population and a department of public health focused intently on helping these individuals and preventing any new infections.

“One thing we’ve concentrated on is for our students to understand the importance of HIV testing, to be well-informed about which individuals need to be tested more frequently, how to interpret the tests and how to initiate ART in someone who has never been treated – with or without consulting an HIV expert,” says Stringari-Murray.

Spreading the Gospel of PrEP

Alyson Decker (MS ’15) learned the lessons well. A graduate of the School’s AGPCNP program and its specialty curriculum, Decker was hired by the San Francisco Department of Public Health (SFDPH) as part of a Centers for Disease Control and Prevention grant called Project PrIDE. The goal is to encourage more providers to test for HIV and initiate pre-exposure prophylaxis (PrEP), to initiate ART within five days for any patients who test positive – and to reconnect people to care who have lapsed.

Decker’s role is to develop relationships with providers throughout the city who work with the highest-risk populations and make sure they understand and feel confident about best practices around PrEP.

Like Ritterman, Decker has had a long interest in and commitment to patients with HIV, having worked with the Shanti Project and having completed a master’s in public health at UC Berkeley in infectious disease. While finishing her UCSF program, she worked at the CCC for two years.

In her current role, she has found that while nearly all primary care providers are aware of PrEP – thanks to a concentrated communication effort that preceded the personal visits Decker provides – big disparities remain in the level of prescribing for both PrEP and ART. Decker hopes to shrink those disparities, because, she says, “Patients are concerned about the stigma of going to an HIV clinic, and, honestly, this is not secret medicine that only a few can prescribe. Our program speaks to the changing epidemic, which I believe is empowering for both patient and provider.”

Goldschmidt agrees. “In most cases, ART is not the most difficult thing in the world, and we’re not asking primary care to assume all care,” he says. “They don’t have to understand ART resistance the way the experts do, just to be able to identify problems and toxicities.”

The challenge is helping primary care providers achieve that comfort level, something that is especially difficult for recent graduates who did not take the additional training. “I’m not sure if you only had that one lecture, you would come out feeling equipped to see HIV-positive individuals – not for treatment, at least. You would need extra support,” says Decker.

Ryan Anson Ryan Anson (MS ’15) believes extra support is always critical. An AGPCNP at the East Bay AIDS Center, Anson provides both primary and HIV care to infected patients, many of whom have complications. After a first career as a photojournalist, Anson did the AGPCNP program and the extra coursework on HIV. “The UCSF program was fantastic, I learned a ton, and it gave me the launching pad I need, but my first week here I was shaking in my boots,” he says.

His UCSF training had prepared him to initiate ART, but he says that understanding multidrug resistance requires on-the-job training and mentorship. “I didn’t see many of these patients in my residencies, and you have the added challenge of supporting people with severe, co-occurring disorders, like methamphetamine abuse, homelessness and poverty,” he says. “In fact, if I had to rank what was more challenging, it’s that aspect of their health that can be hardest to address.”

Decker tells of another NP she met at a conference, who was doing PrEP, but her clinic couldn’t support additional education and didn’t receive reimbursement for all of the services the NP was giving patients during the 15-20 minutes she had to help them navigate complex lives. “Adding another medication, a sexual history, connecting patients to wraparound services when the clinic may not be reimbursed for this work – that’s a challenge,” says Decker.

Responding to the Growing Challenge

Perhaps there’s comfort in the fact that the entire primary care workforce and those who educate that workforce are wrestling with these same challenges.

“My sense is that there is a way to get primary care people trained, but it is nascent,” says Goldschmidt. “I don’t think we can rely on it now at all, and it will have to be built in stages, but we are going to have to come to terms with HIV being a primary care problem for providers already challenged to provide many different services.”

“Four years in, though, I feel more convinced that it can be done,” says Stringari-Murray. “It’s not easy, but we can improve attitudes and get people more comfortable and more confident.”

Each year, UC San Francisco School of Nursing is ranked among the top graduate schools in the nation. Please visit the Family Nurse Practitioner, Adult-Gerontology Primary Care Nurse Practitioner and HIV Minor sections of our website to learn more about our work in these areas.