The University of Massachusetts Department of Family Medicine and Community Health HIV and Viral Hepatitis Fellowship was begun in 2014 in response to the 2010 National HIV/AIDS Strategy Goals:
1) Reduce new HIV infections
2) Increase access to care and improve health outcomes for people living with HIV infection
3) Reduce HIV-related health disparities
There a growing gap between the number of people living with HIV/AIDS (PLWHA) and the number of providers able to properly care for them. Infectious Disease News reported in March 2011 that some ID fellowship programs are not filling, even with foreign medical school graduates. A 2008 survey from the American Academy of HIV Medicine (AAHIVM) found that one-third of HIV specialists, most of whom confronted the AIDS epidemic in its early years, planned on retiring in the next 10-15 years.
Meanwhile CDC data shows that the number of PLWHA in the United States is currently 1.1 million, with an estimated 38,000 new HIV infections annually, but only 48% of PLWHA are retained in care. Coupled with declining HIV providers and falling death rates for PLWHA, this comprises a growing care gap for HIV patients, which is most acutely felt in medically underserved areas. However, there are only three post-graduate HIV fellowship programs in the U.S. (Texas, Idaho and California), and none in the Northeast.
Along with the dynamics of the growing HIV care gap is the recognition that HIV patient care is increasingly dominated by primary care issues. As described by Drs. Selwyn and Chu in An Epidemic in Evolution: The Need for New Models of HIV Care in the Chronic Disease Era (Jour Urban Health. 2011; 88: 556-566.), HIV care moved through three distinct phases characterized by: opportunistic infections and (later) ineffective antiretrovirals (1981-1995), highly-active but often toxic and complicated antiretroviral regimens (1996-2006), and better antiretrovirals but more comorbid chronic diseases (2007+).
More potent, tolerable and widely available antiretrovirals created a new norm of HIV viral suppression with few complications for patients engaged in care. As the mean HIV patient age increases and the typical patient’s HIV management requires less time, other conditions such as diabetes, hypertension, and pulmonary disease take center stage in patient management. This places providers with primary care backgrounds and extra HIV specialty training in an ideal position to provide these patients with the comprehensive care being widely promoted in the Patient-Centered Medical Home model.
Since many of the HIV patients not connected to care in this country are among the high-risk populations served by community health centers, training fellows in and for practice in this setting is aimed at having the greatest impact on all three National HIV/AIDS Strategies. By promoting HIV care excellence based in community health centers, our graduates, and by extension the PCPs they will support, will have a multiplying effect as they become caregivers, leaders and educators. Their influence will both increase HIV testing and education and thereby reduce new HIV infections, and will also narrow the patient care gap and diminish health care disparities for HIV patients.
The inclusion of training in Hepatitis B and C (HBV/HCV) management is based on similar dynamics of increasing overall disease prevalence in the U.S. population, inadequate treatment access, and concentration of infected individuals in community health center (CHC) populations. Chronic HBV and HCV similarly affect the disadvantaged populations served by CHCs, patients who often lack the transportation, language and health literacy to seek care at tertiary care specialty clinics. Furthermore, since chronic HBV and HCV are frequent causes of comorbidity and death in HIV patients, facility with management of these other chronic viral illnesses is a critical skill for an HIV specialist.