Push to end HIV epidemic in US complicated by ‘brain drain’
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Fewer medical trainees are entering the field of HIV, leaving a shortage in the workforce that is likely to get worse, experts said. The trend coincides with slowed progress in reducing new infections, and likely complicates a lofty new federal plan to end the U.S. epidemic in 10 years.
The trend is part of a wider problem: Data show that almost four of every 10 infectious disease fellowship programs were not filled on match day last year.
“Many junior physicians have huge amounts of debt, and they worry about their ability to pay off their student loans on the salary of an ID physician,” said Elizabeth Connick, MD, professor of medicine and immunobiology and chief of the division of infectious diseases at the University of Arizona College of Medicine. “Few express an interest in a career in HIV, and many perceive that HIV has been ‘taken care of’ with potent antiretroviral therapy.”
Infectious Diseases in Children spoke with Connick and other experts about the current state of the HIV workforce and the impact that an HIV “brain drain” will have on patient care, including pediatric patients, and the national goal to end the HIV epidemic by 2030.
HIV ‘brain drain’
Past research has shown that the supply of health care providers for people living with HIV is not keeping pace with the growth in demand for their services. According to one such study published first in HIV Specialist in 2016, the number of HIV providers declined 5% nationally from 2010 to 2015 despite the demand for their services increasing nearly 14%.
Another study published in 2016 in Clinical Infectious Diseases projected that the HIV workforce would be able to accommodate an additional 65,000 patients by 2019 — far short of the estimated additional 100,000 who need care. The study reported that 11% of HIV care providers at Ryan White HIV/AIDS Program-funded facilities and 4% of HIV providers in private practice planned to leave HIV practice within 5 years.
According to Wendy S. Armstrong, MD, professor of medicine at Emory University and past chair of the HIV Medicine Association, 20.7% of all infectious disease positions offered in the 2019 match program went unfilled, and almost 40% of programs were not filled. Armstrong has been monitoring the trends as part of a national effort to build up the HIV workforce.
“This means we don’t have enough people choosing to become ID docs, which is a common pathway to become an HIV provider,” she said. “Those are huge percentages compared to other specialties.”
Armstrong explained that this decline has been ongoing for 5 or 6 years, and although the situation began to improve during that time, the improvement has plateaued.
“We’ve got more people retiring but an increased need — it leaves a substantial shortage,” she said.
Others have observed declines in the field.
“I have definitely noticed a brain drain, with fewer physicians entering the HIV workforce and current practicing physicians leaving clinical practice for industry and research or on the verge of retirement,” said Raghavendra Tirupathi, MD, FACP, medical director for Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine.
Tirupathi said it has been difficult to hire and retain HIV physicians where he works in rural Pennsylvania.
“The problem has only compounded with the opioid epidemic leading to more HIV and hepatitis infections in rural areas of the United States,” he said.
Connick said many senior clinicians in the HIV field have recently left clinical practice to work for pharmaceutical companies, which she says would have been unusual 30 years ago.
“The shortage is likely to worsen, and it is in part due to the fact that a large number of people went into HIV care early in the epidemic and are now hitting retirement age,” Armstrong said. “This was a new epidemic, a new infection, with tremendous pull for people to join the field. That same urgency that was felt at the time is not as strong now, leaving fewer people going into HIV care.”
Impact on patient care
Many studies have shown that people with HIV are living longer and require more care, leading to a need for more trained HIV physicians. Knowing this, experts expect that a waning HIV workforce will negatively impact patient care.
“[HIV care has] become more complex in dealing with other medical problems along with HIV such as drug use, mental health and comorbidities,” Armstrong said. “In some ways, though, HIV care has become more straightforward in that we have many more medications and resistance is less of a problem. What was traditionally an area in which ID providers were the experts, there are now opportunities for others with other training backgrounds to become experts.”
According to Connick, HIV care in the U.S. is being increasingly taken on by midlevel care providers such as nurse practitioners.
“This isn’t necessarily bad — they can provide excellent care. Nevertheless, you still will need ID-trained physicians to oversee this work and be ready to respond to the latest challenges in care,” she said.
Infectious Diseases in Children Editorial Board Member Paul A. Volberding, MD, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco, said patients with HIV often are much healthier than they were in the past and agreed that their care has become easier but that other complications of the disease remain.
“HIV requires the clinicians and care providers to be alert to the social setting, aging issues and comorbidities. HIV is not easy medicine, and we still need an expert workforce, though I think there are some models of care that incorporate a broader team,” he said.
“Interprofessional care is something HIV has really championed,” Volberding added. “We need to ask who the appropriate people are to be involved in the team needed for treating and ending HIV.”
According to Armstrong, the bottom line is that there are not enough of these types of providers to care for the people who need it.
“If you have a new diagnosis of HIV and it’s hard to get into care because of capacity — that’s a huge problem,” she said.
Tirupathi said the problem is even worse in the South, “where, on one hand, there is an epidemic of new infections, and on the other hand, there is a huge shortage of trained HIV physicians.”
The disproportionately poor access to HIV care in Southern states is more apparent among minorities due to many reasons, though lack of provider availability stands out, Tirupathi said.
The NIH has said it will fund various collaborations with medical research institutions to test HIV prevention and treatment strategies in the South, where more than half of all new HIV diagnoses are made.
“Many of these patients have poor housing and transportation in addition to other challenges,” Tirupathi said. “Hence, it would be difficult to retain them in care if there are no local physicians.”
Effects on children
A depleted HIV workforce may also impact care for children and pregnant women with HIV, two vulnerable populations, said Gitanjali Pai, MD, AAHIVS, an infectious diseases specialist at Memorial Hospital in Stilwell, Oklahoma.
“With a declining number of infectious disease providers, there will be a lack of access to HIV care not only for adults, but children as well, who may not get quality care,” she said. “This will worsen the burden of congenital HIV, resulting in children losing their precious childhood years fighting this thus far incurable but very controllable disease and its comorbidities.”
In 2018, between 1.3 million and 2.2 million children aged younger than 15 years were living with HIV globally, including between 110,000 and 260,000 who were newly infected, according to UNAIDS data. There were between 64,0000 and 160,000 AIDS-related deaths.
In the U.S., the annual number of perinatally transmitted HIV infections has declined by more than 95% since the early 1990s, according to the CDC. At the end of 2016, more than 1,800 children aged younger than 13 years were living with diagnosed perinatal HIV, with most infections (63%) occurring in black children. More than 10,000 adults and adolescents aged 13 years or older had perinatally acquired HIV.
Pai noted that among HIV-positive U.S. children aged younger than 13 years, maternal HIV transmission is the most common cause of infection. Although interventions can lower the risk for mother-to-child transmission to as low as 2%, treatment is not widely accessible in many of the global regions where the HIV burden is at its highest, according to WHO.
“This will affect not only the child, but their entire family,” Pai said. “Overall, the field of HIV care will suffer from a lack of quality clinicians and researchers — and hence any further development or progress toward curative treatment as well.”
In addition to other adverse effects, study results have shown that children with perinatally infected HIV show poorer cognitive ability, motor function and attention scores. Results from a study published in December showed that even with early ART initiation, children with HIV showed poorer neuropsychological performance overall than their uninfected peers — underscoring a need for early intervention strategies.
Pai noted the importance of HIV research development specific to children with HIV.
“More than anything, this would be one of the most humanitarian fields to conduct research,” Pai said. “To conduct research in the field of maternal as well as child HIV not only has an impact on the current generation — the mom — but also has the potential to impact the future generation and accelerate our efforts to end the HIV epidemic.”
Ending the epidemic
Last year, President Donald J. Trump announced a 10-year federal plan to end the HIV epidemic in the U.S. by 2030. The plan aims to reduce new HIV infections in the U.S. by 75% in 5 years and by 90% by 2030, all while increasing the use of and access to pre-exposure prophylaxis for HIV prevention.
But experts are unsure if ending the epidemic by 2030 is likely. Recent data published by the CDC showed that progress in reducing the HIV incidence in the U.S. is at a standstill, with the rate of new infections barely decreasing from 2013 to 2017.
“I think that the goal to end the epidemic is ambitious — everyone knows that,” Volberding said. “I don’t think people necessarily agree on what ‘ending’ the epidemic even means.”
He noted challenges posed by stigma and the epidemic occurring in places with poor access to health care.
“We’re going to need more people if we’re going to tackle that ambitious goal,” Volberding said. “We have the tools to end it — the treatment and prevention programs work amazingly well, but we need skilled people to deploy them.”
Connick said the decline in the HIV workforce is just one of several challenges that decrease the likelihood of ending the HIV epidemic by 2030. Tirupathi noted that the situation is “dire” in other parts of the world, including developing countries, where a lack of access to basic testing and treatment impedes care.
“This will not be an achievable goal both in the U.S. and rest of world without adequately investing in HIV graduate medical education and incentivizing physicians to enter the HIV workforce,” Tirupathi said.
Expanding the workforce
Experts agree that more needs to be done to draw medical students and fellows to the HIV workforce, including offering them higher pay.
“Compensation [among ID specialists] is lower than for individuals who don’t pursue the additional training. It’s one of the most poorly compensated fields in medicine,” Armstrong said.
Data published in 2019 showed that pediatric ID specialists were the lowest paid physicians compared with all other medical specialties, and that pediatrics also was among the bottom five specialties.
According to Tirupathi, this creates a situation in which medical trainees burdened with student debt are wary of choosing a low-paying specialty.
“Another big problem,” he said, “is the lack of resources for HIV trainees, which in turn is reflective of the broader trend of inequitable funding for medical education. Primary care physicians also are not being adequately trained in HIV care and are not reimbursed appropriately for the complex care, which is a disincentive.”
According to Volberding, it is not so easy to say if medical students are still energized by the field of HIV, or if they are more excited by other subspecialties.
“ID is still attracting bright people. The problem is complicated,” he said. “The answer depends on where you’re looking. Programs like ours [at the University of California, San Francisco] remain really vibrant HIV centers, and I think the same is not true everywhere, causing a suffering in a lack of applicants.”
Pai believes that early exposure is essential for drawing new talent into the HIV field.
“We need to catch them young,” Pai said. “I believe that introducing trainees early on is important to HIV research, whether it’s through their curriculum, incorporated into their rotations or exposing them to clinical HIV care — not only early, but through all stages of training.”
Connick said the University of Arizona is using several strategies to draw students and residents to careers in ID and HIV, including meeting with active students interested in careers in infectious disease, and engaging undergraduate students and residents as often as possible in HIV-related research.
“Nevertheless, many of these strategies are trumped by the perception that ID is low paying and that trainees will not be able to pay off their debt,” Connick explained.
In addition to compensation issues, Pai noted the burden of administrative work and paperwork in the field of ID. She cited social media as a potentially “powerful tool” to drive interest in the HIV field as well as introduce medical students to a wider variety of infectious diseases.
“We need trainees, clinicians and policymakers to have a long-term picture of the benefit [of HIV research] to humanity to help to end the HIV epidemic,” Pai said. “The bottom line would be that we need to advocate for early exposure to the field, increased compensation and a conducive environment for research and incentives for research. I think as a group, this will help us to see the forest for the trees.”
Unless changes are made and compensation for the HIV workforce improves, shortages are likely to continue and worsen, according to Armstrong.
Legislation introduced in the House in early February would authorize up to $250,000 for loan repayments to clinicians who provide care in areas with shortages of health professionals or at Ryan White sites. If passed, it could reverse workforce shortages, experts said.
“There’s a message out there that HIV is done, it’s over — but it is not. That couldn’t be further from the truth,” she said. “This is such a rewarding field to be in, where any individual involved can have an enormous impact on the lives of the people they care for. I’m a little biased but this — ID and HIV — remain two of the most exciting subspecialties. Medical students and residents need more exposure while training, and they can see that HIV is not over.”– by Caitlyn Stulpin and Eamon Dreisbach
- References:
- AETC Southeast. Strengthening the HIV workforce.https://aidsetc.org/sites/default/files/resources_files/SEAETC_Strengthening_HIV_Workforce_11022016_Final.pdf. Accessed January 17, 2020.
- Boivin MJ, et al. Clin Infect Dis. 2019;doi:10.1093/cid/ciz1088.
- CDC. HIV and pregnant women, infants and children. https://www.cdc.gov/hiv/group/gender/pregnantwomen/index.html. Accessed January 30, 2020.
- Doximity 2019 physician compensation report. Doximity blog. Posted April 2, 2019. https://blog.doximity.com/articles/doximity-2019-physician-compensation-report-d0ca91d1-3cf1-4cbb-b403-a49b9ffa849f. Accessed January 30, 2019.
- Gilman B, et al. HIV Specialist. 2016;(3):2-9. Available at: https://aahivm.org/wp-content/uploads/2017/03/FINAL-AUGUST-ISSUE-8.22.pdf. Accessed December 23, 2019.
- Rabkin M, et al. AIDS. 2018;doi:10.1097/QAD.0000000000001895.
- UNAIDS data 2019. https://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf. Accessed January 30, 2020.
- Weiser J, et al. Clin Infect Dis. 2016;doi:10.1093/cid/ciw442.
- For more information:
- Wendy Armstrong, MD, can be reached at wsarmst@emory.edu.
- Elizabeth Connick, MD, can be reached at connicke@deptofmed.arizona.edu.
- Gitanjali Pai, MD, AAHIVS, can be reached at gpai@stilwellmemorial.com.
- Raghavendra Tirupathi, MD FACP, can be reached at tirupa@keystonehealth.org.
- Paul Volberding, MD, can be reached at paul.volberding@ucsf.edu.
Disclosures: Armstrong, Connick and Tirupathi report no relevant financial disclosures. Pai reports having served on the advisory boards of Abbvie and Gilead Sciences. Volberding reports serving on a data and safety monitoring board for Merck.
Click here to read the At Issue to this cover story, "What is the 'new HIV'?".
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