Push to end HIV epidemic in US complicated by ‘brain drain’
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 out 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 Infectious Disease News Editorial Board Member 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 Disease News 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 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, 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 Infectious Disease News Editorial Board Member 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 U.S.,” 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 in, there are now opportunities for others with other training backgrounds to become experts in.”
According to Connick, HIV care in the United States 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 Disease News Chief Medical Editor 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.”
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 (PrEP) for HIV prevention.
Shortly after, HHS and Gilead Sciences announced an agreement in which Gilead said it will donate free PrEP for up to 200,000 individuals each year for up to 11 years. HHS told Infectious Disease News at the time that the program would focus on underserved, high-risk and low-income areas.
Despite these initiatives, 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. (Editor’s note: For more on this report, click here.)
“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, 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.
According to Tirupathi, this creates a situation in which medical trainees burdened with student debt are “wary of becoming infectious disease doctors.”
“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 UCSF] remain really vibrant HIV centers, and I think the same is not true everywhere, causing a suffering in a lack of applicants.”
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. “It is critical for IDSA to advocate for better salaries for ID physicians relative to other fields. In addition, strategies to decrease the burden of medical student debt are essential.”
Unless changes are made and compensation for the HIV workforce improves, shortages are likely to continue and worsen, according to Armstrong.
“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 — remains one 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
- 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.
- Weiser J, et al. Clin Infect Dis. 2016;doi:10.1093/cid/ciw442.
- For more information:
- Wendy S. Armstrong, MD, can be reached at firstname.lastname@example.org.
- Elizabeth Connick, MD, can be reached at email@example.com.
- Raghavendra Tirupathi, MD FACP, can be reached at firstname.lastname@example.org.
- Paul A. Volberding, MD, can be reached at email@example.com.
Disclosures: Armstrong, Connick and Tirupathi report no relevant financial disclosures. 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'?".