REPORT ORGANIZATION

This report begins with a background section outlining the rationale for expanding HIV testing and the potential challenges of providing quality HIV care to a significantly increased number of patients. The report then summarizes information from the expert presentations and discussion from the public workshop as well as information from a literature review that is relevant to the questions posed to the committee in the third part of the statement of task (see number 3 in Box 1).

The report first examines issues surrounding the capacity of the health care system to administer a greater number of HIV tests. The two primary issues raised relate to the personnel and procedures necessary to implement expanded HIV testing successfully in a variety of different venues and to the personnel and procedures needed to provide counseling and linkages to care for individuals who test positive.

The report next provides information about where HIV-positive individuals currently receive care. It then addresses the question of HIV-related training or experience of most HIV care providers, both in terms of their current experience and training and in terms of changes needed to accommodate a greater number individuals diagnosed with HIV. The next section addresses the current capacity of the HIV/AIDS workforce. The following two sections summarize delivery system strategies and models that might help providers to care for a larger number of HIV-infected patients and strategies to increase the number of providers entering and remaining in the HIV/AIDS workforce. The report then addresses the impact of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) on the public health and clinical infrastructure. The report concludes with a summary of the committee’s conclusions.

BACKGROUND

There is a lack of population-based estimates of the numbers of individuals with HIV who are not in care or on treatment, although studies suggest substantial unmet need. There are an estimated 1.1 million people in the United States living with HIV, of which approximately 21 percent are unaware of their infection and so are not receiving HIV/AIDS care (CDC, 2010c). In addition, one analysis of CDC medical record-based data showed that 45 percent of individuals aged 15 to 49 who have been diagnosed with HIV/AIDS and who are eligible for antiretroviral therapy (ART) are not receiving it (Teshale et al., 2005). Moreover, an estimated 56,000 individuals contract HIV each year (CDC, 2010b).

Approximately 55 percent of adults between 18 and 64 years of age and 28 percent of people at higher risk for HIV have never been tested (CDC, 2010c). Identification of undiagnosed HIV-positive individuals is important because early treatment improves the health outcomes of persons infected with HIV¹ and decreases the likelihood of transmitting the virus to others. However, enhanced screening efforts and subsequent linkages to care for previously undiagnosed individuals and for previously diagnosed individuals who do not receive regular care will place increased demands on organizations and individual health care providers.

The present capacity of the health care system to administer a greater number of HIV tests and to accommodate a significant increase in the number of HIV-infected individuals in care is strained. Julie Scofield, Executive Director, National Alliance of State and Territorial AIDS Directors (NASTAD), described the situation as a “perfect storm.” The U.S. recession has led to an increased demand for publicly supported services on the part of those with, or at risk for, HIV. Although resources were insufficient to support the demand for HIV prevention, testing, and care before the economic downturn, federal and state budget cuts in response to the financial crisis have made it more difficult to meet the increased demand for services. At the same time, expanded HIV testing initiatives in response to CDC recommendations to promote routine HIV testing (CDC, 2006) have brought more individuals into care.² In addition, earlier and more effective treatment has greatly improved survival among HIV-positive individuals. It is estimated that by 2015 one half of people living with HIV/AIDS will be over the age of 50 (Effros et al., 2008; Myers, 2009). Although most of these individuals are long-term survivors of HIV, in 2007, people age 50 and over accounted for 16 percent of new HIV diagnoses (CDC, 2007). Figure 1 shows the increase in the number of people living with HIV/AIDS from 1977 to 2006.

FIGURE 1

HIV incidence and prevalence, United States, 1977–2006. SOURCE: Hall et al., 2008.

In the face of this success, however, serious concerns have arisen regarding the health care system’s ability to meet the growing demand for HIV testing, access to medications, and linkages to sustained care.

Additional factors that affect the ability of the workforce to address the needs of HIV-positive individuals include the complexity of care resulting from improved survival (older individuals with HIV often experience more complex psychosocial and care needs, including increased stigma, dementia, and other comorbidities [GMHC, 2010]), the relatively low numbers of new providers specializing in HIV care, severe provider shortages in rural areas and urban centers with high minority concentrations, and the need for increased cultural competency among providers to treat an increasingly diverse client population (HRSA, 2010c). At the same time, the initial wave of HIV care providers are approaching retirement age and are either reducing their practices or retiring completely. Taken together the increasing demand for HIV care services and anticipated decrease in the relative number of providers practicing HIV medicine raises concerns about the ongoing ability of the workforce to meet the needs of the HIV/AIDS population in the United States, especially as enhanced screening efforts are expected to increase the number of individuals diagnosed with HIV.

Additionally, changes that are anticipated to result from the ACA potentially could further increase demand on the HIV care workforce. Medicaid is the largest single source of care and coverage for people with HIV with approximately 40 percent of patients receiving services through Medicaid (KFF, 2009b). Medicaid expansion under the ACA expands income eligibility to a national floor of 133 percent of the federal poverty level and is expected to bring millions of low-income individuals, including individuals with HIV, into the Medicaid program. The elimination of categorical eligibility requirements, such as disability, for Medicaid under the ACA is also likely to bring many more individuals with HIV into the program (IOM, 2010).

Grave concern exists about the capacity of the health care workforce to implement expanded testing for HIV throughout the United States and to provide competent HIV/AIDS care to significantly increased numbers of patients. A variety of approaches will be needed to respond to these challenges. The current comprehensive and integrated model of care often exhibited by Ryan White-funded clinics provides a foundation upon which future care systems could be structured.³

EXPANDED HIV TESTING

Since the beginning of the HIV epidemic, HIV testing and counseling traditionally have been administered by providers who are specifically trained in these areas, and providers not trained in HIV testing and counseling would refer patients out to those who were. As a result, providers who have practiced in this environment are less well-equipped to mentor their students and residents in the provision of HIV testing. The practice of referring patients for HIV testing may also have contributed to patients’ belief that their provider does not perform HIV testing. A cultural shift is needed within the education of students and residents so that over time providers become better equipped to perform HIV testing and counseling and less inclined to refer their patients elsewhere.

Timely diagnosis and treatment can improve survival and quality of life among HIV-positive individuals and reduce the likelihood that they will transmit the disease to others. These reasons provide impetus to increase identification of previously undiagnosed HIV-positive individuals through measures such as the 2006 CDC recommendations for routine screening for HIV for individuals between the ages of 13 and 64 (CDC, 2006). Between 2006 and 2009, the percentage of Americans aged 18 to 64 who reported being tested for HIV at some point in their lives grew only from 40 percent to 45 percent (CDC, 2010c, p. 2). In light of continuing efforts to increase testing for HIV in the United States, the committee was asked to evaluate the current capacity of the health care system to administer a greater number of HIV tests.

In a recent survey of the 65 jurisdictions receiving CDC funding for HIV prevention activities, 75 percent (43 health departments) reported providing financial and programmatic support for the implementation of routine HIV testing for all patients 13 to 64 years of age, in accordance with the 2006 CDC recommendations (NASTAD, 2010, p. 12). Of the 43 health departments that provided support for routine testing, the greatest majority (79 percent) supported routine testing in sexually transmitted disease (STD) clinics. Sixty percent supported routine testing in hospital emergency departments (EDs) and community health clinics, and 51 percent supported routine testing in substance abuse treatment centers, correctional facilities, and family planning clinics (see Table 1).

TABLE 1

Health Care Settings in Which Health Departments Support Routine HIV Testing.

The first report of the Committee on HIV Screening and Access to Care discussed the various barriers and facilitators to expanding access to HIV testing (IOM, 2010). Recent data from the CDC indicate that in 2009 82.9 million adults between 18 and 64 years of age in the United States reported having been tested at least once for HIV, which represents an increase of 11.4 million since 2006 when the CDC recommendations to expand HIV testing went into effect (CDC, 2010c,e). Despite the progress that has been made, it is estimated that 55 percent of adults (including 28.3 percent of adults with a risk factor for HIV) still have never been tested for HIV (CDC, 2010c,e). Increased testing within the senior population faces unique or greater challenges, such as the stereotype that seniors are not sexually active, greater resistance to discussing sexual activity with health care providers, less knowledge about HIV transmission and prevention, and unique biological risk factors (GMHC, 2010; Myers, 2009).

Kathryn Hafford, Director, Division of Disease Prevention, Virginia Department of Health, described how a survey conducted two years after Virginia changed its law to be consistent with CDC recommendations found that despite educational outreach efforts, providers did not know that written informed consent was no longer needed prior to administering a routine HIV test. Rates of documented routine prenatal HIV testing did not increase following the state’s change in law. Experience with routine prenatal testing varies from state to state, however. In Rhode Island, for example, prenatal testing increased from about 53 percent in 2006 to more than 90 percent following implementation of routine opt-out testing ( Alexander et al., 2009). Hafford indicated that additional provider training is needed so that the legal obligations regarding HIV testing are clear.

Once these and other barriers to the implementation of expanded HIV testing are overcome, the question remains whether various components of the health care system have the capacity to provide such screening. In addition to the need for adequate space to permit privacy when interacting with patients about HIV testing, the primary concern about capacity centers on the question of a sufficient number of adequately trained personnel. A second, somewhat related, general concern is the degree to which testing can be incorporated into the present work flow at facilities. The greater the extent to which it can, the less the need for additional personnel to accommodate the associated tasks.

Hafford explained that the Virginia Department of Health, as in most other states, has received substantial funding to develop and promote routine testing programs around the state. The health department found that the capacity and desire to implement testing programs, as well as the need for support, vary greatly among venues. Some providers say that all they need is funding for test kits and the testing procedure or to hire additional staff; others say that they will not implement a program unless the health department provides the staff.

Incorporation of routine HIV testing into office visits with family practitioners and other primary care providers may present smaller obstacles in terms of logistics and provider capacity. However, some providers do not view such testing as their primary responsibility, and some dismiss the need for such screening among their patients, whom they may view as being at low risk for HIV. This is another area in which provider education may prove beneficial in helping to increase the number of tests performed. In general, however, health department support for HIV testing has resulted in more testing in private settings. Hafford pointed out that many providers are not opposed to testing, but indicated that some providers feel overwhelmed by the prospect of diagnosing and caring for HIV-positive individuals and that they often do not know how to expand HIV testing. Additional training to increase providers’ familiarity and comfort with the processes of HIV testing (e.g., counseling and referral mechanisms for patients diagnosed with HIV, as well as guidance in incorporating routine testing into their practices) may be beneficial here as well.

Based on her experience with health department supported testing programs in Virginia, Hafford reported that testing in non-primary-care settings increases when support is provided but that such increases require a great deal of support. New HIV testing programs in these settings have been successful in identifying previously undiagnosed HIV-infected persons, but staff members have required oversight to ensure that quality standards surrounding testing are being met. In addition, peer navigators had to be hired to ensure that individuals who test positive are linked to care.⁴

Since EDs are likely to see patients at higher risk for HIV, testing for HIV in EDs may help to identify individuals with undiagnosed HIV infection. However, there are barriers to the implementation of increased HIV testing in EDs. Compared with patients in other medical settings, patients visiting EDs may be more difficult to locate once they leave. Consequently, conventional HIV testing for which results would not be available during the same visit may not be performed because of provider liability concerns. Use of rapid HIV tests, which generate results within minutes, can help to address this concern and reduce the number of people who fail to receive their test results (Branson et al., 2006). The administration of rapid HIV testing in EDs has been found to be acceptable to ED providers and patients (Brown et al., 2007; Freeman et al., 2009; Merchant and Catanzaro, 2009).⁵

Other barriers to increased HIV testing in EDs remain however. Most notably, because ED providers are concerned with addressing their patients’ immediate health care needs, they may not have the time or other resources to perform routine HIV testing. As discussed in greater detail later, use of hospital-based laboratories for the processing of rapid tests (or expedited processing of conventional tests) would help to address some of these concerns and may help HIV testing fit more seamlessly into the ED workflow and minimize the impact on existing personnel.

Providers also may be concerned about how to approach individuals about HIV testing. Several issues arise, including a lack of comfort among many providers in addressing matters pertaining to individuals’ sexual history and practices. Providers additionally are concerned about the amount of time potentially needed to counsel patients who test positive and link them into care. Hafford described how providers who have worked with HIV/STD or high-risk clients are more comfortable with providing HIV testing. However, providers without such experience often feel unprepared to handle a positive test result. In fact, she mentioned that some providers in her state ask the health department to handle all positive test results. She indicated that education and guidance in this area are needed and that health professional schools are not spending enough time training students in taking a sexual history and providing counseling.

Hafford indicated that, as frequently is the case in hospital EDs, some community health centers (CHCs) already are so overwhelmed by patient case loads that they resist the addition of routine screening to the services they provide. Often the CHCs that are most interested in establishing routine HIV testing are in rural areas with a lower percentage of HIV positive individuals. These centers have the time and the personnel to introduce routine testing, but they do not see many HIV-positive patients, raising the issue of how to prioritize the distribution of health department support for routine HIV testing programs.

Finally, Hafford noted the difficulty the Virginia health department has experienced in getting buy-in to routine screening from correctional facilities. For example, testing within correctional facilities (and some other high-risk settings) often depends on the willingness of the health department to provide counseling and other services associated with the identification of a positive case. Committee member Beth Scalco mentioned that this dependence on the health department support is also present in Louisiana.

Andrew Young, Associate Professor, Emory University School of Medicine, also provided the committee with information on the capacity implications of expanded HIV testing, addressing both the ED and clinical laboratory settings. HIV testing in EDs can occur by either rapid testing or expedited conventional testing⁶ in the hospital laboratory or by rapid testing directly at the point of care. Young discussed the advantages and disadvantages of each approach.

The advantage of conventional testing when next-day turnaround times are acceptable (e.g., for hospital inpatients) is the laboratory’s ability to accommodate a greater increase in testing, due to automation, without additional equipment, testing personnel, or training, according to Young. However, the implementation of routine testing programs with immediate processing of samples so that results become available during the patient encounter creates challenges for laboratories and testing personnel. Although such immediate testing is favored by many organizations because of better patient acceptance, follow-up, and linkages to care (Freeman et al., 2009; Haukoos et al., 2008; Jain et al., 2008), laboratories may not be able to provide expedited conventional testing for a large number of specimens because conventional HIV tests often are performed on batch analyzers. Different equipment, such as random-access analyzers,⁷ likely would be necessary to provide continuous expedited testing, but not all laboratories have such equipment. Therefore, in order for in-house laboratories to support extensive HIV testing through expedited conventional testing, new funds, space, and personnel likely would be needed. In addition to these laboratory-specific resources, new hospital staff, resources, and training may be needed to process test orders, obtain and transport specimens, report and receive positive results, and counsel a greater number of patients diagnosed with HIV.

Different challenges arise with point-of-care HIV testing. Although administration of rapid tests at the point-of-care allows clinicians to receive and transmit results more quickly during a patient encounter (i.e., results are available within minutes, compared with hours for expedited conventional testing), it can raise issues related to capacity and quality assurance. Young described how for clinic- or office-based testing, RNs or other personnel undertake a manual process that can take 20 to 40 minutes. According to Young, in low-volume, low-acuity settings, where there is limited access to clinical laboratories, rapid HIV testing is useful and feasible. In busy EDs, however, more pressing patient concerns, such as life-threatening trauma or medical emergencies, may distract personnel from the testing process. Since the accuracy of the test results depend on reading the test within the timeframe specified by the manufacturer, the possibility of the tester being occupied by other duties may lead to a greater number of false negatives or positives or wasted time and materials, when clearly invalid tests must be discarded. Young noted that to avoid specimen errors, only one patient (or very few) should be tested at one time.⁸

Young also expressed concern about ensuring compliance with Clinical Laboratory Improvement Amendments (CLIA) standards in non-laboratory-based testing, even when CLIA-waived rapid tests are being used. The Clinical Laboratory Improvement Amendments⁹ regulate all laboratory testing performed on humans in the United States and list legal standards for waived testing. The Food and Drug Administration (FDA) defines tests as “waived” or “not waived” from CLIA based on their level of complexity (Table 2). Waived tests are those that generally are easy enough to administer at home, that carry minimal risk of harm, and that therefore have less stringent requirements. Non-waived tests have more stringent requirements (e.g., personnel qualifications, quality management).

TABLE 2

Approaches to Routine HIV Screening.

Young cited Centers for Medicare and Medicaid (CMS) surveys revealing high rates (e.g., 20 percent) of noncompliance with CLIA standards (Howerton et al., 2005). These issues arise in testing at the point of care, even when simple CLIA-waived tests are used. The Joint Commission on Accreditation of Healthcare Organizations also lists standards for waived testing in accredited health care organizations, with similar high rates of noncompliance (JCAHO, 2010). If clinical personnel were to add high-volume, manual HIV screening to their existing duties, the risks of noncompliance would probably increase significantly. Thus, point-of-care screening may require the addition of dedicated staff. The concern about CLIA compliance would be reduced if expedited laboratory testing were available.

Much of the literature on point-of-care rapid HIV screening comes from large hospital EDs, with externally funded programs and dedicated staff trained in point-of-care testing (Arbelaez et al., 2009; Brown et al., 2007; Haukoos et al., 2010; White et al., 2009). Documentation of testing and test results, as well as meeting administrative reporting requirements, is time-consuming. In addition, the costs per test and risks of regulatory noncompliance are greater. Young indicated that these point-of-care testing programs may not be sustainable over the long term, or be able to expand to test a larger percentage of emergency room traffic without additional external resources.

Young discussed the point-of-care rapid testing program being conducted at a Grady Health System ED as part of a CDC demonstration project (THRIVE Project). Through August 2010, there was high test acceptance (85 percent) and more than 10,000 patients were tested. The program has identified 172 patients with new preliminary HIV diagnoses (1.7 percent of those tested). Young characterized the program as successful, but he indicated that it has reached capacity in terms of the number of HIV tests that can be performed in the ED with available staff and resources, despite having hired dedicated staff (a full-time program coordinator/HIV counselor; two additional, full-time HIV counselors; and a half-time database manager) to manage the testing and linkages to care. There are approximately 150,000 visits to the Grady ED each year, so routine HIV testing has been extended to only a fraction of patients seen there. In addition, since CDC funding of the program has helped to cover the cost of the dedicated staff to administer the tests, provide counseling, and link those who test HIV positive to follow-up care, the sustainability of the program following the demonstration stage is questionable.

Instead of extensive use of point-of-care HIV testing in high-volume EDs, Young advocated movement toward an expedited laboratory-based HIV testing program. If sites can develop good systems for rapid ordering of tests and transport of specimens, in-house laboratories could immediately process HIV tests, just as they process emergent tests such as those for cardiac markers in heart attack patients. Such programs would require laboratory staff and equipment capable of processing HIV tests on an expedited basis around the clock, as well as a plan and hospital staff person to explain the results and arrange linkage to care for those individuals who test positive. But because of the need for other expedited testing in laboratories, the long-term sustainability of such a program is more assured.

Another possibility would be the use of hospital laboratories to process rapid HIV tests rather than conducting them in the EDs. According to Young, this approach would help to ensure around-the-clock availability of trained personnel, lessen the risk of regulatory noncompliance, and potentially avoid the need to purchase new laboratory equipment. However, Young noted, the need to transport rapid tests to the central lab would eliminate much of the advantage of the quick turnaround time for rapid tests; the cost of performing rapid HIV tests is much greater than with automated analyzers; and regardless of where they are performed, rapid tests pose a significant challenge for high-volume testing because of the total lack of automation.

In response to a question from committee member Scott Burris, Young discussed the difficulties of providing counseling in the context of a busy ED and the need for dedicated staff to ensure that prevention messages are communicated, both to patients who do and do not test positive for HIV, and that patients who test HIV positive are linked to appropriate follow-up care. Hafford mentioned that EDs in Virginia often rely on the health department to handle the counseling needed for those who test positive. In higher risk settings, such as STD clinics, the HIV counseling is handled by clinic staff. Committee member Beth Scalco described how, in Louisiana, EDs rely on hospital-based infection control nurses to provide counseling and linkages to care. Registered nurses, along with testing counselors, can be effectively utilized in the provision of testing, prevention counseling, and care linkage for individuals who test positive.

Young also raised concerns about a rise in the rate of false positive tests as routine HIV screening programs are implemented in lower prevalence areas. This problem will be minimized by the relatively high accuracy of HIV testing, although high false positive rates have been reported (Walensky et al., 2008). The problem could be further addressed by use of rapid tests (in the clinical laboratory or at the point of care) for confirmatory diagnostic purposes, as well as screening. In this model, patients would not be informed of positive results until they are verified by a second rapid test. Currently, the FDA has only approved Western blotting and RNA hybridization for confirmation in the United States, but it is considering approval of rapid tests for this use.

Young mentioned the advent of “fourth generation” assays for HIV antibody and antigen and discussed how they might improve screening. These fourth generation assays can detect acute HIV infection, when antibodies have not yet developed but viral antigen and RNA are present. Patients with acute infection who are unaware of their status are more likely to engage in high-risk behavior. They are also at high risk for transmission due to their high viral load. To date, the FDA has approved one fourth generation assay for use as an aid in the diagnosis of HIV infection, including acute or primary HIV infection (FDA, 2011), with others under review (Abbott, 2010).

In terms of administrative issues, Young mentioned the uncertainty over the provision of reimbursement for HIV screening tests, given insurers’ policies to limit payment for preventive services to those rated highly by the U.S. Preventive Services Task Force (USPSTF).^10,11

Young identified the need to educate hospital leaders, through organizations such as the American College of Healthcare Executives, about the importance of HIV screening and opportunities for funding. High-level administrative involvement is critical in large health care systems to ensure institutional endorsement of screening and to provide the necessary leadership and resources to clinical departments and laboratories, so that their roles are coordinated and HIV screening programs are affordable, sustainable, and compliant with regulations. He also discussed the merits of support for demonstration programs that would allow clinical laboratories to explore methods to expedite testing to meet the needs of EDs and other settings where routine HIV testing is taking place.

The SAMHSA National Survey of Substance Abuse Treatment Services, an annual census of substance abuse treatment centers throughout the United States, helps to assess the availability of HIV testing and ancillary services for HIV (including early intervention services and education and counseling) in substance abuse and treatment centers (SAMHSA, 2010). The survey can help to identify locations where there may be gaps in HIV testing and ancillary services.

WHERE PERSONS WITH HIV CURRENTLY RECEIVE CARE

Laura Cheever, Deputy Associate Administrator and Chief Medical Officer, HIV/AIDS Bureau, Health Resources and Services Administration (HRSA), provided the committee with an overview of the limited data available on patterns of care for HIV/AIDS patients. Unfortunately, the most comprehensive study of sites of HIV/AIDS care is from the HIV Cost and Services Utilization Study (HCSUS) (Bozzette et al., 1998), which was conducted from 1994 to 2000 and the data from which are now outdated. More recent data are available from Ryan White providers, but the sample is limited to those receiving Ryan White funding. A current effort to compile nationally representative data on people living with HIV/AIDS who are receiving care in the United States is the Medical Monitoring Project,¹² although data pertinent to this report are not presently available.

HCSUS collected information on a nationally representative sample of people in care for HIV infection. The data are now more than 10 years old, and the epidemic has shifted in demographic and clinical terms. However, HCSUS found that in 1996, HIV/AIDS patients in care were seen predominantly in private physicians’ office practices, hospital-based outpatient clinics, and community/neighborhood clinics (Table 3). It is unknown the extent to which source of care patterns are similar today or whether they have changed with the shifts in the HIV epidemic.

TABLE 3

Usual Source of Care for Individuals with HIV/AIDS in Care, United States 1996.

Along with Medicaid, an essential source of care for the estimated 529,000 uninsured and under-insured persons infected with HIV in the United States is the Ryan White program administered by HRSA. The Ryan White program is the single largest federal program designed specifically for people with HIV/AIDS, including the nondisabled poor and undocumented immigrants. The program is considered a lifeline in terms of its payments for health and dental care, medications, and other services (e.g., case management and transportation) that are not covered by other funding sources and complete a comprehensive program of care for people with HIV/AIDS.¹³ There is, however, considerable variation in the availability of Ryan White services across the country, since federal Ryan White funding is provided to state and local jurisdictions, which tend to tailor services based on the needs of local communities (Rawlings and Hopson, 2009).¹⁴

Cheever presented 2009 Ryan White program data showing that there were nearly 390,000 medical clients served by 876 Ryan White-funded care sites (Table 4).¹⁵ Hospital-based clinics provide medical care to almost half (48 percent) of these clients. Publicly-funded CHCs, other community-based organizations (CBOs), and health departments provide medical care to another 47 percent of the clients at Ryan White-funded sites. Additional providers of medical care services include private doctors’ offices, day treatment programs, home care programs, skilled nursing facilities, and correctional facilities (New York State Department of Health, 2006).

TABLE 4

Medical Clients Served within the Ryan White Program (All Parts), 2009, by Provider Type.

The AIDS Drug Assistance Program (ADAP) is a component of the Ryan White program that provides HIV-related prescription drugs to low-income people with HIV who have limited or no prescription drug coverage. Approximately 183,000 HIV-infected people received medications through the ADAP in 2009. Approximately one-third of people with HIV receiving care are estimated to be enrolled in the program (KFF, 2009a).

Sixty-two percent of Ryan White medical provider organizations are not-for-profit, and 35 percent are publicly owned. Just under half (45 percent) are minority organizations (i.e., more than half of board members or professional staff represent racial/ethnic minorities), and 41 percent historically have served racial/ethnic minority clients (Cheever, 2010, citing unpublished HRSA/HAB program data for 2009).

The high volume of HIV/AIDS care provided in the Ryan White-funded clinics has led to their becoming centers of expert HIV care in the United States. Part C of the Ryan White program funds planning grants, capacity development grants, and grants to service providers to support early intervention outpatient services and ambulatory care. Figure 2 shows a map of the Part C-funded outpatient clinics in the United States with more clinics in regions where HIV is more heavily concentrated.

FIGURE 2

Ryan White Part C outpatient care centers of expert HIV care in the United States, 2010. SOURCE: Kitahata, 2010 (HRSA Geospatial Data Warehouse—2010).

Despite the success of Ryan White-funded clinics as models for the provision of expert HIV care in the United States, a 2008 survey of Ryan White Part C-funded programs¹⁶ conducted by the HIV Medicine Association (HIVMA) and the Forum for Collaborative HIV Research showed that a majority of the programs reported that it was difficult or very difficult to recruit physicians (69 percent), NPs (56 percent), and PAs (57 percent) to serve their clients (Weddle and Hauschild, 2010; personal communication with Andrea Weddle, January 21, 2011).

Steven Johnson, Medical Director of the Mountain-Plains AIDS Education Training Center and Professor of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, pointed out that in areas of high HIV/AIDS prevalence, newly diagnosed patients are likely able to access expert HIV programs. In lower prevalence areas, however, where there are no such programs, patients may have to see providers with less HIV training and experience. This is the case in his experience as the Medical Director of the Mountain-Plains AETC that serves an eight-state region¹⁷ where there may be just a few HIV expert programs per state. In the Mountain-Plains region, there are many areas of low prevalence, and low population density, in a large geographic area. It may be especially difficult for uninsured and/or undocumented residents of rural or frontier areas to find care.

In addition to medical care, Ryan White providers offer comprehensive ancillary services. Examining the array of services available to clients helps to understand staffing needs at these care sites. Table 5 shows the extent to which case management, treatment adherence, mental health, substance abuse, oral health, and other services are provided by Ryan White funded sites. The table shows a heavy reliance on nonmedical support personnel (e.g., social workers and outreach workers). The provision of support services improves retention in care (Sherer et al., 2002).

TABLE 5

Services Provided by Ryan White Care Sites (All Parts), 2009.

There has been a dramatic increase in the number of clients served in Ryan White clinics in the past decade. Figure 3 shows a 59 percent increase in the number of clients served in Ryan White Part C clinics from 2001 to 2009, with a concurrent increase in funding of only 8.6 percent, representing a decline in dollars per client served of about one-third.

FIGURE 3

Ryan White Part C clients and funding, 2001–2009. SOURCES: KFF, 2009c; Andrea Weddle, personal communication with HRSA HIV/AIDS Bureau, 2009.

HIV-RELATED TRAINING AND EXPERIENCE OF HIV CARE PROVIDERS

The committee was asked to explore the HIV-related training or experience of HIV care providers (i.e., physicians, PAs, advanced practice registered nurses [APRNs]/NPs, and RNs) as well as improvements in training or experience that are needed to help absorb an increased number of newly diagnosed individuals as a result of expanded HIV testing services. The discussion of “HIV care providers” is complicated by the numerous specific subgroups that provide medical care for individuals with HIV/AIDS. Within each of the health professions listed (physicians, PAs, APRNs/NPs, and RNs), practitioners may have specialized training or experience in the provision of HIV/AIDS care or have minimal training or experience in HIV/AIDS care yet be called upon to provide care to patients with HIV. For example, there are (1) non-HIV/primary care providers (e.g., physicians, APRNs, and PAs who have no specialized training in or significant experience with HIV/AIDS care), (2) HIV/primary care providers (e.g., physicians, APRNs, and PAs who have specialized training in and/or significant experience with HIV/AIDS care), (3) non-primary care/HIV/infectious disease specialists (e.g, physicians who are HIV/infectious disease specialists, but provide no routine primary care for their patients), and (4) primary care/HIV/infectious disease specialists (e.g, physicians who are HIV/infectious disease specialists, but provide routine primary care for their patients). For patients receiving HIV and primary care from more than one provider, the definition of and critical interactions between “primary care” and “HIV” interventions may become blurred. For example, does the management of hyperlipdemia, a frequent complication of HIV medications, fall within the realm of the “non-primary care HIV” provider or the “primary care” provider?

To the extent possible, this report applies the following designations:

• HIV care providers: any health care providers who routinely care for one or more individuals with HIV/AIDS;
• Primary care providers: physicians, APRNs/NPs, and PAs who are trained to provide primary care to patients (they may or may not also be certified, credentialed, or experienced in HIV/AIDS care);
• Infectious disease specialists: physicians sub-boarded in infectious diseases (they may or may not also serve as the principal source of primary care for their patients and may or may not be experienced in HIV care); and
• Generalists: health care providers who have neither specialized nor are certified, credentialed, or experienced in HIV/AIDS care.

Primary care providers (physicians, APRNs/NPs, PAs) provide much of the medical care for individuals living with HIV/AIDS. Since the early years of the epidemic, substantial and similar proportions of persons with HIV have received their HIV-related care from primary care providers and from infectious disease specialists. In some analyses, primary care physicians have comprised more than half (56–58 percent in two studies) of physicians who care for persons with HIV (HRSA, 2010c).

In a 1997 to 1999 survey of physicians¹⁹ designated by patients as their HIV provider found that 60 percent were generalists and 40 percent had infectious disease training (RWJF, 2008). About one-third of the generalists did not consider themselves to be HIV experts, whereas only 4 percent of those specializing in infectious disease reported that they were not experts in HIV (RWJF, 2008). Andrea Weddle, Executive Director, HIV Medicine Association, provided the committee with data on the medical specialty distribution of the membership of HIVMA, an organization of medical professionals, including physicians, NPs, PAs, and other professionals, who practice HIV medicine. Among the 3,155 members who responded to a HIVMA survey, 71 percent are adult infectious disease specialists and 7 percent are internal medicine providers (personal communication with Andrea Weddle, December 2010).²⁰

THE CAPACITY OF THE HIV/AIDS CARE DELIVERY SYSTEM

The capacity of the HIV care workforce to accommodate an increased demand for care by persons with HIV depends upon both the availability of sufficient positions and the availability of providers to fill those positions. In terms of the latter, projections indicate that the supply of HIV providers is not keeping up with demand for HIV care (HRSA, 2010c). In addition, funding cuts and reductions in available positions that support HIV programs that have occurred, such as in health departments (NACCHO, 2010), may decrease the health care system’s capacity to provide care for more persons with HIV.

Capacity Implications of the Aging HIV/AIDS Workforce

The committee was asked to address whether the age profile of providers is compatible with sustainability of the HIV care delivery system. Specifically, “are younger clinicians and/or students receiving adequate training/experience to meet future needs?”

With regard to the health care workforce in general, an estimated 33 percent of physicians and 24 percent of pharmacists are expected to reach retirement age by 2020 (AAMC, 2010; HRSA, 2010c) and are either reducing their practices or retiring altogether. The AAMC Center for Workforce Studies projects a shortage of 45,000 primary care physicians by 2020 (AAMC, 2010). The nursing workforce currently includes substantial numbers of nurses who are reaching retirement as well as a high proportion of nurses at the beginning of their careers. A 2006 report prepared by the Center for Health Workforce Studies, School of Public Health, University at Albany, projected that 45 percent of RNs in 2006 would reach retirement age by 2020 (CHWS, 2006). The report further estimated that total replacement needs for APRNs due to retirement would exceed 61,000, with at least 40,000 replacement openings for NPs (CHWS, 2006). Midcareer nurses, the group most needed to fill the roles of those leaving the workforce and with the knowledge, experience, and mentoring that senior nurses can provide, are the lowest in number (Bleich et al., 2009; IOM, 2011a). Almost 65 percent of professionally active dentists in 2006 were age 45 or older (ADEA, 2008), and 44 to 46 percent are expected to retire by 2020 (CHWS, 2006; HRSA, 2010c). Other providers are closing their practices due to underfunding (HRSA, 2010c). At the same time, the United States population is expected to increase by 29 percent between 2000 and 2030 (HRSA, 2010c), and the average age of the overall population is increasing as well, resulting in more people seeking care. The numbers of new providers entering the workforce are projected to be inadequate to meet the growing demand.

There are no current nationally representative estimates of the size and demographic composition of the HIV workforce. To help the committee better understand the implications of the aging HIV/AIDS workforce, Andrea Weddle presented information on the age distribution of the 3,155 U.S.-based members of HIVMA, the majority of whom are physicians. Forty-five percent of the workforce is more than 50 years of age and the proportion by decade of age is highest for those 51 to 60 (Table 6).

TABLE 6

Age Distribution of U.S. HIVMA Members, 2010.

These findings are consistent with a 2008 survey of 400 providers and student members of the American Academy of HIV Medicine (AAHIVM).³² Almost one-third of the respondents reported that they were in the last quarter of their careers, with plans to retire within 10 years (Carmichael et al., 2009). A majority of respondents were concerned about impending shortages of HIV providers as more than 90 percent of them reported that they had seen an increase in patient load in the last 2 years.

Adele Webb provided information on the aging of the nursing workforce. The average age of registered nurses in the United States is projected to be 44.5 years by 2012, meaning that nurses close to retirement age are expected to be the largest segment of the RN workforce in the next five years (AACN, 2010). The number of nurses over age 50 more than quadrupled between 1983 and 2009, and the number of middle-aged nurses (age 35-49) doubled. Together these two age groups comprise almost 75 percent of the nursing workforce (IOM, 2011a). In terms of nurses specializing in HIV/AIDS care, Webb reported that nearly 60 percent of ANAC members are between 40 and 50 years of age (Association of Nurses in AIDS Care database, compiled by Kimberly Carbaugh, September 2010), while only 7 percent of ANAC members are 20 to 29 years old, evidence that recent nursing school graduates are not entering the HIV/AIDS field at a pace necessary to keep up with future needs.

Just as the physician and nursing workforces are aging, so too is the public health workforce, which serves an essential role in the delivery of HIV prevention and care services and programs. This is occurring at the same time as demands for services in the areas of surveillance, education, administration, and care have increased. Kathryn Hafford provided the committee with data pertaining to the public health workforce. The Association of Schools of Public Health has estimated that 250,000 more public health workers will be needed by 2020 (ASPH, 2007). However, this workforce is diminishing, forcing public health workers to do more with fewer resources.

In addition to shortfalls in training, the public health workforce is aging. According to a 2007 workforce trends profile, the average age of a state public health worker was 47 and within three years, 20 percent of State Health Agency’s workforce would be eligible to retire. The public health occupation most frequently cited as experiencing a severe worker shortage was public health nursing (ASTHO, 2007).

DELIVERY SYSTEM STRATEGIES TO MAXIMIZE CAPACITY OF CURRENT WORKFORCE

The committee was asked to examine the increases in workforce that would be needed to provide care for the greater number of newly diagnosed HIV-positive individuals expected to result from expanded HIV testing services. This issue is all the more pressing in light of the anticipated provider shortages outlined in the previous section and the anticipated increase in the number of individuals previously diagnosed with HIV accessing health care in the wake of the ACA and more effective efforts to bring people into care. In general terms, there are two approaches to increasing provider capacity. The first, addressed in this section, utilizes delivery system strategies to maximize the capacity of the current health care workforce to care for HIV-positive individuals. The capacity of current providers can only be expanded so much, however. At some point more personnel are needed to accommodate further increases in demand. The second approach employs “pathway” strategies, discussed later in the report, to increase the number of HIV care providers (HRSA, 2010c).

Increased and more effective use of several strategies would help to maximize the ability of the current HIV care workforce to absorb an influx of newly diagnosed individuals, and/or a reduction in the number of available providers. These strategies include task shifting, comanagement, and care coordination models, including medical homes and integrated delivery systems.³⁶

STRATEGIES TO INCREASE THE NUMBER OF PROVIDERS ENTERING AND REMAINING IN THE HIV/AIDS WORKFORCE

The committee was asked to address the impediments to professionals entering into, or continuing to provide, HIV/AIDS care, as well as policies that inhibit or enhance the movement of health care professionals into HIV/AIDS specialties.

Two physicians, each of whom has delivered care to HIV/AIDS patients for more than two decades, Michael Saag, President of the HIV Medical Association, and Joel Gallant, Professor of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, described the changing face of the practice of HIV care. They contrasted the care environment that existed in the early days of the epidemic to the care environment today (Table 7). Indeed, most of the presenters invited to speak on the topic described the changing face of the epidemic as one important impediment to the ongoing provision of HIV care and to the movement of health care professionals into HIV/AIDS care.

TABLE 7

HIV/AIDS Care: Then and Now.

In the following sections, the impediments to new providers entering the HIV/AIDS workforce are described for different professional groups. Following that is a discussion of the challenges of retaining professionals in the field of HIV/AIDS care.

Barriers to Expanding the HIV/AIDS Workforce

Physicians

A number of factors affect HIV/AIDS physician shortages, but key issues identified by Saag, Gallant, and Johnson include financial disincentives, inadequate education/training opportunities, unattractive characteristics of the practice environment, and “reverse brain drain” (see later discussion), in which physicians interested in HIV medicine may pursue what they perceive to be the more interesting challenges of international HIV/AIDS care. Other contributing factors include a reluctance to work with HIV patients, geographic considerations, and more general issues such as too few openings in medical schools.

Financial disincentives Saag pointed to the general unattractiveness of contemporary primary care practice in general as a significant inhibition for entry into HIV/AIDS care. Recently trained graduates of medical schools are typically heavily indebted. The average educational debt of medical school graduates in 2009 was $156,456. Eighty-seven percent of graduating medical students carry outstanding loans (AMA, 2009). When examining their options, graduates know that physicians in primary care settings earn much less than their specialty counterparts and often work longer, less predictable hours. Because of the complexity of HIV/AIDS care, the need to address multiple medical and psychosocial issues when providing care, and the relatively poor patient population served, providers may be unable to cover the expenses of their practices.

Saag shared financial data from his clinic in Birmingham, Alabama, showing very poor physician reimbursement, even for fully insured patients. He suggested that if the Ryan White program were not in place, practices specializing in HIV/AIDS care would not be sustainable. Loida Bonney, Assistant Professor of Medicine, Division of General Medicine, Emory University, stated that the median salary for an assistant professor in infectious disease is approximately $130,000 per year, compared to $148,000 for an assistant professor in general internal medicine (AAMC, 2009).

Inadequate education/training opportunities Since many graduates leave medical school without adequate exposure to HIV/AIDS care, they may never have considered focusing their postgraduate training on this area of medicine. Gallant described how medical students have few opportunities to train with HIV experts and to see them as mentors or role models because of the paucity of medical education taking place in the outpatient and community-based settings where HIV/AIDS care is now provided. According to Webb, this lack of familiarity with HIV/AIDS care is common among nursing graduates as well. Trainees who have had an opportunity to work in public clinics serving poor patients are more likely to work in such settings following graduation.

Gallant described a 2004 HIVMA survey of first-year internal medicine residents conducted in the 10 states with the highest HIV prevalence. Of 729 residents surveyed, 40 percent indicated an interest in working in HIV medicine or research. Of those, 79 percent reported that they would prefer to prepare for a career in the HIV field through a 1-year focused HIV training program instead of a 2- to 3-year fellowship. Fifty-one percent of respondents said that their medical residency had not prepared them to practice HIV medicine.

Gallant went on to describe another study, a 2008 survey of internal medicine program directors that concluded that internal medicine residents were unprepared for HIV care management (Adams et al., 2010). Although 42 percent of program directors felt that it was important to train residents to be primary care providers for HIV-infected patients, only 19 percent of directors felt that their graduates had the necessary skills. The responding program directors reported the belief that patients prefer to be seen, and receive better care, in infectious disease or HIV clinics than in general medicine clinics, despite the evidence that many HIV/AIDS patients receive care from primary care providers without specialty training in HIV/AIDS. (The response rate to this survey was 62 percent [230 of 372 program directors responded].)

Gallant also discussed the results of a survey conducted to gauge knowledge about antiretroviral drug therapy among physicians caring for hospitalized HIV-infected patients in two community teaching hospitals. In response to a series of 10 clinical scenarios based on antiretroviral prescribing errors, infectious disease or HIV specialist physicians were relatively well informed (the mean percentage of correct answers was 93 percent for infectious disease or HIV specialist physicians), while resident physicians and attending nonspecialist physicians did not perform as well (the mean percentage of correct responses was 33 percent and 37 percent, respectively) (Arshad et al., 2009). High scores were associated with the number of HIV outpatients seen per month and the reported comfort level in managing HIV-infected patients. Errors included those related to dose, frequency, renal dosing, drug interactions, and missing agents.

Gallant discussed how the acknowledgment of evidence showing that “expert” HIV/AIDS care improves health outcomes for HIV/AIDS patients may have discouraged primary care providers from even considering this as an area of special interest, despite the fact that studies indicate that providers’ amount of experience in caring for HIV/AIDS patients (i.e., number of patients served) is a better indicator than specialty training of the quality of care they provide.

Unattractive practice environment Most HIV/AIDS care is provided in outpatient settings, with much of the care provided in publicly supported clinics. Stephen Boswell contrasted the practice environment typical of general outpatient care settings to that of CHCs where HIV/AIDS patients are often seen. Considering all of the health providers available, the ratio of patient to staff is somewhat lower in general outpatient care settings than that typically seen in community health centers (958 vs. 1,092) (Table 8). As Table 8 illustrates, there is a greater burden of care placed on physicians in CHCs as well as a greater reliance on nursing support. Boswell pointed out that not only are patient-to-staff ratios higher in CHCs, the patients cared for in these settings are often poor and disenfranchised with a complex array of medical and social problems that must be addressed. To meet these needs physicians, PAs, NPs, and RNs in CHCs rely on the services provided by medical assistants, medical social workers, and outreach workers.

TABLE 8

Staffing Patterns and Benchmark Ratios for Workforce Projections.

Bonney described how HIV/AIDS providers working in very busy out-patient settings, frequently without adequate workforce support, are often stressed. Stress and the inability to manage work stress (i.e.,“burnout”) are regular consequences of HIV care (Benevides-Pereira and Das Neves Alves, 2007; Brown and Lescano, 2000; Gerbert et al., 2004; Saag, 2006). These issues affect primary care in general. Medical graduates understand these issues in the context of the substantial income disparities affecting HIV/AIDS and other primary care fields, and opt to enter other medical specialty fields at the expense of primary care. Boswell provided data on changes in residency positions from 1998 to 2006, showing a shift away from primary care and toward specialty practice. The percentage of graduates choosing family practice residencies declined by 51 percent, while those choosing anesthesiology increased by 150 percent (Figure 4). Boswell indicated that in his experience, issues related to the quality of life of a primary care provider are as important as compensation in deterring graduates from pursuing primary care as a career. He highlighted the administrative burdens of primary care practice, for example, spending an hour on paperwork and administrative tasks for every hour of clinic time.

FIGURE 4

Percent change in percentage of U.S. medical school graduates filling select residency positions, 1998–2006. SOURCE: Woo, 2006.

“Reverse brain drain” Finally, another barrier to providers entering the domestic HIV/AIDS workforce is a kind of “reverse brain drain.” Gallant mentioned the sense that providers in training may perceive HIV/AIDS as a problem of the past and/or as no longer a “cause.” Kitahata observed the need to refocus HIV domestically, noting that the President’s Emergency Plan for AIDS Relief (PEPFAR) has raised the visibility of HIV care in international settings. For those with some interest in HIV/AIDS, attention has shifted to the interesting challenges of international work. The tendency for providers thinking about careers in HIV medicine to consider working abroad was mentioned by Kitahata, Cheever, and committee chair Paul Cleary.³⁹

Nursing Professionals

A key factor affecting the shortage of APRNs and RNs to accommodate increases in HIV testing and care is the lack of training programs resulting, in part, from a shortage of nursing school faculty (IOM, 2011a). Thousands of qualified nursing school applicants were not admitted to nursing programs in 2009 because of a lack of faculty, according to Webb. With respect to the capacity of the HIV workforce, the problem of this shortage is compounded by the specialty choices made by graduates of nursing programs. Few young nurses are selecting HIV as a specialty. Non-specialist nurses may lack the specific knowledge, competence, and confidence to provide adequate HIV testing and care. Webb anticipates that the HIV care workforce, under an expanded testing framework and in the context of changes resulting from the ACA, cannot practically accommodate an increased demand without consideration of the training needs of all levels of nursing professionals.

With respect to financial incentives, practicing and experienced nurses often opt out of HIV nursing because of more attractive compensation in other specialty fields.

As discussed previously, RNs and APRNs can earn advanced certification or credentials in HIV care (e.g., ACRN, AACRN, AAHIVM credentials). However, they do not necessarily reap financial or professional gains if credentialed, as they would in other specialties, Webb indicated. Additionally, the reimbursement to experienced HIV APRNs may be inadequate for the complex care that they provide to their patients.

Webb pointed out that all nursing professionals and other health professionals working in Ryan White-funded clinics depend on the program’s continued reauthorization as well as adequate appropriations for continued employment at their clinics. Health professionals working in Ryan White clinics depend largely on grant funding. This instability of funding sources can lead to a sense of job insecurity, making these settings less attractive than other, better supported, sites of care.

Webb described how FQHCs and Nurse Managed Health Centers⁴⁰ are increasingly asked to take on the role of providing HIV/AIDS care in lieu of AIDS service organizations. The overall shortage of APRNs and RNs specializing in HIV/AIDS care and the rapid expansion of these Health Centers have created acute shortages of nursing professionals at these facilities. Educational opportunities and financial incentives will be necessary to ensure that there is a sufficient supply of qualified APRNs and RNs to handle the influx of HIV/AIDS cases following more widespread HIV testing and the expansion of CHC program capacity after implementation of the ACA. Webb discussed the importance of special outreach to ensure that RNs and APRNs at these facilities have the training and education needed to provide quality HIV treatment and care. Webb concluded her remarks by observing that an adequate supply of appropriately trained nursing professionals and other health care providers underpins the success of any expanded framework of care for HIV patients.

Physician Assistants

Jean Davis spoke about the importance of PAs in the provision of HIV/AIDS care. She noted the importance of focusing on health care capacity in HIV/AIDS, not only from a clinical perspective, but also from that of cultural competency and fluency. Cultural competency encompasses not just race and ethnicity, but gender, age, biological sex, and so on.

Davis noted that there are no programs that specifically train PAs for HIV/AIDS care, although PAs can participate in the AAHIVM credentialing program. She emphasized the importance of including training in taking a sexual history from patients. HIV/AIDS as a topic should be discussed when learning about the reproductive health system, dermatology, and infectious disease.

PAs should also be exposed to HIV patients as they do their rotation in internal medicine. However, since most HIV/AIDS patients receive routine care in outpatient settings, there may not be adequate exposure to HIV care in hospital-based rotations. Davis recommends that there be a specific HIV rotation for PA students, where they do a rotation in facilities where HIV/AIDS patients are being seen.

Davis concluded her presentation by noting that fellowships allowing specialization in HIV/AIDS care and loan repayment programs would be incentives for PAs to specialize in HIV/AIDS care. She also noted the importance of ensuring that there are enough providers of all types that are people of color in order to provide care for patients living in communities of color.

Implementation of steps to address a number of these issues, such as improved training in taking sexual histories, increased exposure to HIV medicine in outpatient settings, and perhaps even programs to enable more underrepresented minorities to enter primary care (e.g., loan subsidies and repayment options) may be relatively inexpensive strategies to help meet capacity needs.

IMPACT OF THE AFFORDABLE CARE ACT ON THE PUBLIC HEALTH AND CLINICAL INFRASTRUCTURE

Jeffrey Levi, Executive Director, Trust for America’s Health, provided the committee with an overview of the issues related to the testing and treatment of HIV-infected individuals and the potential impact of the ACA. Levi cited literature supporting the need for insurance reform for HIV-infected individuals. According to a recent CDC study of 21 U.S. cities, 57 percent of HIV-infected men who have sex with men are uninsured. Furthermore, 81 percent of those who were unaware of their HIV infection had not visited a health care provider in the past year (CDC, 2010d).⁴⁵ This study provides further evidence that expanding insurance coverage and improving provider capacity could greatly increase opportunities to bring many at-risk individuals into care.

Levi outlined some of the shortcomings of the health insurance system that have limited access to care for HIV-infected individuals. First, Medicaid traditionally has been restricted to those who are very poor and who also meet certain criteria, for example, those who are disabled, pregnant, or children. Second, Medicare eligibility for people under age 65 has been restricted to those who have long-term disabilities (i.e., 29 months, with two waiting periods) and there have been limits to prescription drug coverage (i.e., the “donut hole”) whereby, after a certain amount of charges for prescription drugs has been incurred, beneficiaries are temporarily responsible for paying 100 percent of their prescription drug costs (RWJF, 2010). Third, private insurers often deem HIV-infected individuals uninsurable or require high premiums and/or lifetime limits on coverage for those they have insured.

Levi reviewed provisions of the ACA that will improve health insurance coverage for individuals with, or at risk for, HIV/AIDS. By 2014, the ACA will greatly expand Medicaid to cover individuals with incomes up to 133 percent of the federal poverty level (FPL). In addition, income level will be the sole eligibility criterion with no need to meet additional categorical requirements (e.g., disability). Until 2014, states may elect the option to extend Medicaid to individuals with incomes up to 133 percent of the FPL. In addition, for Medicare beneficiaries there will be a gradual closing of the prescription drug coverage gap beginning in 2011 (RWJF, 2010). In the private insurance market, there will be guaranteed issue⁴⁶ of health insurance by 2014 (and a mandate to have health insurance coverage). Private insurers will have to limit their underwriting to age, geography, and smoking history (e.g., no HIV history restrictions). Subsidies will be available for those with incomes between 133 and 400 percent of the FPL and who are unable to afford private health insurance (covering both premiums and cost sharing). By 2014, routine costs associated with participation in clinical trials also will be covered by private plans.

Coverage of preventive services under the ACA will expand as well but will vary by insurance provider:

• New plans offered by private insurers will be required to cover, without cost sharing, preventive services rated A or B by the USPSTF, immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), and certain preventive care services recommended by HRSA for infants, children, adolescents, and women.
• Under Medicaid, the federal government will offer a 1 percent increase in the federal match to states that offer Medicaid coverage of, and remove cost sharing for, A and B USPSTF recommended services and ACIP recommended immunizations (effective January 1, 2013).
• Medicare will eliminate cost sharing for Medicare-covered preventive services that are USPSTF recommended A or B services.

As mentioned earlier, routine HIV screening (i.e., testing of those not at increased risk) is rated C by the USPSTF and therefore is not included in the aforementioned extensions of coverage (IOM, 2010).

Boswell described how reimbursement for HIV care provided in health centers will be affected by the ACA. The ACA requires insurance exchanges to include all 340B eligible providers,⁴⁷ such as FQHCs and state ADAP programs, in their networks. Also under the ACA, insurance exchanges will pay FQHCs no less than the rate provided under their Medicaid prospective payment system (PPS) (a method of reimbursement where payment is based on a predetermined, fixed amount). Payment to FQHCs for patients covered by Medicare will be based on a modified PPS that includes all preventive benefits and elimination of current caps and screens. A phased transition of financing HIV/AIDS care is needed as future methods of reimbursement under the ACA are untested and will require years to develop (e.g., accountable care organizations [ACOs], Alternative Quality Contract).

Although many ACA provisions will not be phased in until 2014, some are effective immediately:

• Individuals denied insurance coverage due to a pre-existing condition have immediate access to federally subsidized high-risk pools.
• Private insurers cannot rescind an insurance policy, for example, canceling insurance after a claim is made.
• Pre-existing condition exclusions for children have been eliminated.
• Lifetime caps on coverage have been eliminated and annual caps have been subject to regulation.
• Coverage of children under a family plan has been extended to age 26.

Levi described some of the efforts to expand health care capacity under the ACA:

• To expand the safety net, $11 billion has been allocated over the next 5 years to CHCs.
• In FY 2010, $30 million was made available to the CDC, of which $21.6 million is to be used for HIV testing.
• As of 2013, temporary improved reimbursement rates will be offered to Medicaid providers (these Medicare reimbursement rates will expire after 2014).
• Community Transformation Grants will begin to be available in 2011 to facilitate policy, structural, and environmental change favoring prevention.
• A program to support community health workers will be supported as of 2011.

In conjunction with previous investments made through the American Recovery and Reinvestment Act, provisions of the ACA are designed to support the training, development, and placement of more than 16,000 new primary care providers over the next 5 years. Among other efforts, an allocation of $250 million from the Prevention and Public Health Fund⁴⁸ in 2010 is providing new resources for the training of 500 new primary care physicians by 2015, more than 600 new PAs, and 600 additional NPs. The allocation also helps to establish new NP-lead clinics in medically underserved areas and provide support for states to develop and implement strategies for expanding their primary care workforces over the next 10 years.⁴⁹ Although not specifically addressing the need for more HIV/AIDS providers, these steps should help to increase the primary care workforce in general.

The ACA has several provisions to support quality improvement efforts. HIV issues are included on the agenda for comparative effectiveness research. Major investments in health information technology also will improve capacity for HIV surveillance and for measuring the quality of HIV care.

Levi pointed out that although expansions in coverage and focus on prevention are welcome, they do not necessarily guarantee adequate access to preventive services and care. Many challenges to the implementation of the ACA remain. For example, yet to be determined is the “essential health benefits package” that insurers will be required to cover. States will be determining the full range of benefits for the expanded Medicaid population so there likely will be significant variation across the country. States can choose between the relatively comprehensive standard Medicaid package and a “benchmark” program that would be more like a private plan. In addition, the makeup of health care provider networks is not well defined. Whether Ryan White providers or “expert” HIV providers will be included in networks is to be determined. Finally, how reimbursement for HIV testing will be administered is unclear. For example, alternative testing sites that currently receive grant support for HIV tests may be required to submit insurance claims for individuals with insurance coverage.

The fate of the Ryan White program after implementation of the ACA is also uncertain. Ryan White was initially meant to be a temporary measure until more fundamental changes in health care insurance and provision could be developed. Over time the Ryan White program has evolved to accommodate new and emerging needs. Originally designed in part to provide emergency assistance to areas disproportionately affected by the HIV epidemic, it now serves to fill gaps in medical care and to provide support services that are not covered by other funding sources. Many workshop participants raised concerns over the many services that are needed by persons living with HIV that are not generally covered by health insurance. These wraparound services, such as case management and substance abuse and mental health services, may be vulnerable under the ACA. Prescription drug coverage under ADAP is an essential Ryan White program whose future is uncertain now that the ACA has been passed. The Ryan White program also has been able to provide services to individuals who are excluded from health care coverage under the ACA.

In his remarks, Boswell suggested that to better understand how best to allocate scarce personnel and resources, studies are needed to document models and best practices for HIV care. The CMS Innovation Center, for example, could evaluate the impact of the Ryan White model for patient-centered, medical-home care on patient outcomes and costs of care.

Levi concluded his remarks by pointing out that until 2014, there are opportunities to gain coverage of vulnerable populations through high-risk insurance pools and to make investments in preventive services. By 2014, there are opportunities to redesign health care programs to meet the needs of those who are in need of HIV/AIDS services.

Committee member Ron Bayer asked Levi to describe how the Ryan White program might be reshaped after implementation of the ACA. He pointed out that the Ryan White program covers some essential services that health insurance was never designed to address (e.g., outreach and patient navigation). The demand for some services, now covered by Ryan White, will decline as uninsured individuals gain coverage. Levi and Cheever raised the concern that the reauthorization of the Ryan White program will take place in 2013 before full implementation of the ACA. There are risks associated with changing the program before the implications of the ACA are known.

Arleen Leibowitz from the committee asked Levi about reimbursement mechanisms that might be used by ACOs and whether risk adjustment has been considered to take into account the complex care requirements of HIV/AIDS patients and others with chronic conditions. Levi replied that these types of adjustments are needed, but that decisions about such reimbursement mechanisms have not yet been made.

Committee member Eric Bing asked Levi about options that undocumented individuals will have in terms of gaining insurance. Levi replied that undocumented individuals with HIV may have access to care through CHCs, which do not have the same restrictions as other programs with respect to the individuals to whom they may provide services. Access to care for undocumented individuals would depend on the adequacy of support going to CHCs.

Committee member Scott Burris asked about marginalized populations’ access to care following implementation of the ACA, for example, individuals who are in and out of prison and/or who use intravenous drugs. Levi mentioned that many such individuals would be eligible for Medicaid and that ease of enrollment will be important to ensure access to care. Another issue for this population is whether culturally competent providers will be available in provider networks and whether a usual provider of care, for example, a community-based clinic dependent on discretionary support, will remain as a viable provider following implementation of the ACA.

Committee member Martin Shapiro asked whether certain portions of the ACA are more vulnerable to legislative change than others and whether, in the wake of the ACA, the Ryan White Care Act may be vulnerable. Levi replied that support for the Ryan White program has, in general, been constant and bipartisan. In terms of the ACA, Levi pointed out that retaining popular aspects of reform (e.g., elimination of underwriting) while repealing other less popular provisions would have significant fiscal ramifications that would be identified by the Congressional Budget Office. Consequently, in his opinion, changing the ACA may prove difficult.

Committee member Susan Cu-Uvin called attention to the centrality of CHCs in the ACA and asked Levi to anticipate how HIV/AIDS patients would be served following the implementation of the ACA. Would patients, for example, receive primary care from a CHC and then get referred to a Ryan White program for HIV/AIDS specialty care? She observed that many HIV/AIDS patients receive all of their care, primary and specialty care, within Ryan White programs. Saag added that the shifting focus to CHCs for HIV care is a potential threat to Academic Health Centers that want to remain engaged in HIV care. Levi indicated that the main factor that will determine the site of patient care is the makeup of provider networks. It is unclear in the early days of the ACA how the networks will be defined and whether Ryan White providers will routinely be included in them. Levi speculated that there will be a redistribution of money in the system that will potentially also affect the distribution of patients across care sites.

Levi suggested that HRSA may need to resolve some issues around its “payor of last resort” provisions. Ryan White providers are obligated to obtain reimbursement for services rendered from all available insurers before using Ryan White dollars. With an expanded population of individuals with third party insurance, Ryan White programs will be in a position to seek third party reimbursement more often. If health care services are being supported through insurance payments, Ryan White funds might be redirected to other services.

When asked by committee chairman Paul Cleary to outline his main conclusions, Levi indicated that there are three main areas to consider as the ACA is implemented:

1.

How health care benefits are defined by insurers and which clinicians (including, e.g., APRNs and PAs) should be included in provider networks are the main “threshold” issues for HIV/AIDS care providers and patients under the ACA.

2.

Ensure that HIV/AIDS is a fundamental part of new prevention initiatives such as the Community Transition Grants and the community health workers program.

3.

Maintain discretionary program funding streams that provide wraparound services needed by HIV/AIDS patients at least until full implementation of the ACA and evaluations are completed to assess the adequacy of HIV/AIDS services under new delivery and reimbursement structures.

SUMMARY

In the wake of the 2006 CDC recommendations to implement routine HIV testing in health care settings for individuals 13 to 64 years of age, state health departments and other organizations are receiving financial support for the development and implementation of HIV screening. However, it is not clear whether the support has been sufficient, and the long-term sustainability of the programs is in question, especially once outside funding ceases. It is clear that sustainable programs need to fit as seamlessly as possible into the care flow of the venues in which they are instituted, which will necessitate the use of different testing procedures in different venues. A willingness and flexibility to develop and implement procedures that best match the needs of the setting are important to the success of expanded HIV testing efforts. A big challenge to the implementation of routine HIV testing, especially in busy, high-volume settings where patient follow-up is more challenging, is the question of who will inform and address the needs of individuals who are found to be HIV-positive. Providers in these and other HIV testing venues may have neither the comfort level nor perceive themselves to have the expertise to respond to these patients. In addition to training for providers on the provision of HIV counseling and education, the availability of resources (e.g., computer/Internet tools) to help providers link patients with care and treatment, as well as psychosocial support, could help in this regard.⁵⁰

In assessing the current capacity of the health care system to incorporate an increased number of HIV-positive individuals into care, the committee encountered a paucity of data on patterns of care for HIV/AIDS patients. The most comprehensive, nationally representative study of sites of HIV/AIDS care is the now dated HIV Cost and Services Utilization Study. Although more recent data are available from Ryan White providers, that sample is limited to those receiving Ryan White funding. Similarly, there is a lack of data on the HIV-related training of providers.

Nevertheless, it is clear that primary care physicians, infectious disease specialists, APRNs, and PAs provide the vast majority of medical care for HIV-positive individuals. Registered nurses, dentists, pharmacists, and social workers are among the providers necessary to provide quality HIV/AIDS care in a variety of settings. In terms of training, one of the challenges is the emergence of HIV as a chronic medical condition, increasing the complexity of treating HIV-positive individuals. Infectious disease specialists and primary care providers who are HIV experts due to substantial patient care experiences, formal training, or both, are generally better-prepared to manage HIV disease than are primary care generalists, who lack such experience or expertise. However, most HIV-positive patients can benefit greatly from the broader skills of primary care providers in addressing their other health care needs.

Another clear message is the lack of adequate provider training and experience in HIV care, especially in outpatient clinics, where most routine HIV care now occurs. Increased exposure of trainees to outpatient HIV care throughout school and post-graduate (residency) training, as well as new and ongoing provider training through continuing education programs, is crucial to developing and maintaining a sufficient supply of appropriately trained providers to accommodate increased numbers of HIV-positive individuals.

Moreover, there are more clinicians retiring from or leaving HIV care than there are new clinicians entering the field. At the same time, the number of HIV-positive patients in care is growing, due to increased longevity as well as increased numbers of newly diagnosed individuals. Efforts to bring into care individuals with HIV who currently do not receive regular care will further increase that number. For example, the changes to Medicaid eligibility criteria under the ACA are likely to increase the number of individuals with HIV accessing care. It is important to have not only adequate numbers of HIV care providers, but also adequate racial/ethnic diversity and cultural competency among providers given the large percentage of HIV patients from racial/ethnic minority populations (HRSA, 2010a).

A number of strategies could help to maximize the capacity of the health care workforce to accommodate the increased demand for HIV care. Delivery system strategies, such as task shifting, comanagement, and care coordination models, including integrated delivery systems, are designed to maximize the capacity of the current workforce to provide quality care to HIV-positive individuals. “Pathway” strategies are designed to increase the supply of HIV-trained care providers through, for example, greater exposure of trainees to HIV care and financial and other incentives to encourage more providers to enter HIV care.

The current and projected capacity of the health care workforce to implement routine testing for HIV throughout the nation and to provide competent HIV/AIDS care to significantly increased numbers of patients is of grave concern. Clearly, a variety of approaches will be needed to meet the needs for diagnosis and treatment of HIV-positive individuals in the United States. In addition, barriers to the ability of providers such as APRNs to practice to the full extent of their education and training will need to be addressed. The current Ryan White model of care, which provides a wide range of medical and nonmedical services, allows for task shifting across provider levels to the extent permitted by state regulations, and supports the provision of comprehensive services, offers an example of the type of integrated delivery system that serves HIV/AIDS clients well and upon which future care systems could be modeled.

Regardless of the approach taken, the committee was impressed by the urgency of addressing these HIV/AIDS care capacity issues. With each additional HIV infection detected, the care system inherits a responsibility to counsel, refer, treat, and monitor an additional patient, at an average per-infection cost of $19,912 per year (Gebo et al., 2010). Interruptions in care, such as have occurred with the freeze on some ADAP programs, and the provision of inadequate care due to long waiting periods and provider shortages are costly not only in human suffering and lost productivity, but also in increased transmission, with each new infection adding a very costly liability for the future ($355,000 for HIV treatment alone [CDC, 2010a]).

Footnotes

1

At least one-third of individuals who test positive for HIV in the United States are tested too late to receive full advantage from treatment (CDC, 2010b).

2

See the committee’s report of the first workshop, Exploring Barriers and Facilitators to Expanded HIV Testing (IOM, 2010) for a discussion of the 2006 CDC recommendations for routine HIV screening.

3

As noted in a 2001 IOM report, integrated care helps to overcome the problems of patient “handoffs” that slow down care, voids in patient coverage for care, loss of information, and failure to build on the strengths of all health professionals involved to ensure that care is appropriate, timely, and safe (IOM, 2001).

4

Hafford estimated that the cost per successful linkage is from $1,000 to $1,200. This estimate includes provider education and training and the staffing time needed to promote linkages to care.

5

Conventional testing refers to the use of ELISA (or enzyme immunoassay [EIA]) tests to detect the presence of HIV antibodies in blood, oral fluid (mucus, not saliva), or urine. The test takes 3.5 to 4 hours to run, but samples generally are processed in batches and frequently are sent to outside labs, resulting in a wait of a day or two to 1 to 2 weeks for the result (http://www​.cdc.gov/hiv​/topics/testing/resources/qa/index.htm [accessed March 3, 2011]; San Francisco AIDS Foundation, 2009). Rapid testing refers to the use of a test strip to detect the presence of HIV antibodies by visually comparing the test window to a control window. Similar to a home pregnancy test, rapid HIV tests provide results in as little as 20 minutes (http://www​.cdc.gov/hiv​/topics/testing/resources/qa/index.htm [accessed March 3, 2011]; San Francisco AIDS Foundation, 2009).

6

Expedited conventional testing would involve the hospital laboratory running a conventional HIV test either individually or in small batches so that the results could be delivered while the patient is still in the ED. In addition to other drawbacks, such an approach still would require a number of hours to perform, making it less timely than the use of rapid testing.

7

For more information, see http://www​.hivandhepatitis​.com/recent/2008/060608_e.html (accessed March 3, 2011).

8

November 2010, the Food and Drug Administration approved a new rapid test for HIV-1 that provides results in as little as 60 seconds (Klein and Struble, 2010). The test requires a fingerstick or venipuncture to obtain blood, unlike some other rapid tests that can be run on oral fluids. However, the very rapid result time may facilitate usage and streamline routine HIV testing in busy hospital-based settings and help to extend routine HIV-testing to novel venues.

9

See http://www​.cms.gov/CLIA/ (accessed March 3, 2011).

10

This issue was discussed at length during the committee’s first workshop (IOM, 2010). The ACA mandates that insurers cover preventive health services given A or B rating by the USPSTF. The USPSTF gives an A rating to HIV screening for high-risk patients, in high-prevalence settings (≥ 1 percent) and for pregnant women, but only a C rating for standard-risk patients in lower-prevalence settings (USPSTF, 2007). If an A or B rating is not obtained for standard-risk, lower-prevalence groups, screening programs may not be financially viable.

11

In some states and territories, however, legislation has been passed that requires private health insurers to cover routine HIV testing. This is the case in California (see California Assembly Bill 1894-Health Care Coverage and HIV Testing), and similar legislation has been introduced in other states.

12

See http://www​.cdc.gov/hiv​/topics/treatment/MMP/index.htm (accessed February 25, 2011).

13

Besides a confirmed HIV diagnosis, to be eligible for care and support services through the Ryan White program, persons must have an income too low to pay for care and have no insurance or not enough insurance to pay for care (HRSA, 2011).

14

A more detailed discussion of the Ryan White Program appears in HIV Screening and Access to Care: Exploring the Impact of Policies on Access to and Provision of HIV Care (IOM, 2011b).

15

There may be slight duplication in the estimates of the number of medical clients, if clients received services from multiple sites.

16

Sixty-eight percent (246 of 363 grantees contacted) responded to the survey.

17

The eight-state region includes Colorado, Kansas, Nebraska, New Mexico, North Dakota, South Dakota, Utah, and Wyoming.

18

There is currently no population-based system to quantify the number of individuals with HIV who are not in care. Using one of the largest data sets available, analyses by Teshale et al. (2005) showed that about 45 percent of individuals with HIV/AIDS between the ages of 15 to 49 who were eligible for ART were not receiving it.

19

Some patients designated NPs or PAs as their primary care providers.

20

The American Academy of HIV Medicine (AAHIVM) also supports the HIV care provider and profession through continuing medical education (CME), credentialing, provision of practice management information, and other activities. The committee did not have recent data on the medical specialty distribution of AAHIVM members. According to the AAHIVM website, its approximately 2,000 members are composed of physicians, nurses, PAs, and pharmacists (AAHIVM, 2011b).

21

Category 1 CME involves formal educational activities, including documentation of acceptable needs assessment, learning objectives, educational design, an evaluation method, and disclosure, that are implemented in compliance with Accreditation Council for Continuing Medical Education standards and certified for credit by an accredited continuing medical education provider.

22

See http://www​.hancb.org/certification.htm (accessed March 3, 2011).

23

See http://www​.ptcny.com/clients/HANCB/ (accessed March 3, 2011).

24

The information about AAHIVM credentialing is drawn from AAHIVM (2011a), as well as a prior version of the website that was last accessed on February 22, 2011.

25

In 2008, the AAMC suggested that there were approximately 228,000 physicians practicing patient care AAMC (2008).

26

See http://www​.statehealthfacts​.org/comparetable​.jsp?ind=773&cat​=8&sort=1771 (accessed March 3, 2011).

27

ANAC represents approximately 2,700 nurses specializing in HIV care (Webb, 2010).

28

Often affiliated with nursing schools, Nurse Managed Health Centers provide health care services in underserved areas to individuals who are un- or underinsured.

29

To increase the size of the primary care workforce, the ACA (Sec 5508A) authorizes $25 million in FY 2010, $50 million in FYs 2011 and 2012, and “such sums as may be necessary” in subsequent years to encourage “teaching health centers” (THCs) to expand or establish new primary care residency programs. The law defines a THC as an entity that (1) is a community-based, ambulatory patient care center, and (2) operates a primary care residency program (AAMC​.org [accessed October 5, 2010]).

30

Residency consists largely of an apprenticeship approach to learning through service to hospital inpatients and outpatients under the guidance of an attending physician, although training may focus more heavily on inpatient care. According to a 2008 IOM report, it is during rotations on inpatient services that residents are more likely to have 80-hour work weeks (IOM, 2008).

31

With regard to informed consent, the CDC recommendations state that general consent for medical care should be considered sufficient to encompass consent for HIV testing (Branson et al., 2006).

32

AAHIVM includes both physician and non-physician providers of HIV care.

33

Forty-five states responded to at least one 2009 survey.

34

Forty state HIV/AIDS programs responded to the 2010 initial survey as of September 17, 2010 (a follow-up survey will be conducted at year’s end).

35

See http://www​.statehealthfacts​.org/comparetable​.jsp?ind=552&cat=11 (accessed March 21, 2011).

36

This section draws heavily from “Workforce Capacity in HIV” (HRSA, 2010c).

37

A detailed discussion of these and other barriers is provided in The Future of Nursing (IOM, 2011a, Chapter 3).

38

HealthHIV functions as the AETC National Center for HIV Care in Minority Communities.

39

Similar observations were made by several speakers at the 2008 National Summit on HIV Diagnosis, Prevention and Access to Care (http://hivforum​.blogspot​.com/search?q=brain+drain [accessed March 1, 2010]).

40

Nurse Managed Health Centers offer family practice primary care services emphasizing health promotion and preventative care. The NPs and nurse midwives at the centers provide complete health care and are recognized as primary care providers under the terms of most medical insurance plans (Institute for Nursing Centers, 2011).

41

Title VII of the Public Health Service Act was enacted in 1963 in response to a shortage of health care providers. Title VII programs are designed to encourage providers to practice in underserved areas, increase the number of primary care providers, and increase the number of minority and disadvantaged students in health care programs and faculty in health care education and training programs. There has been a reduction in Title VII funding in recent years (APHA, 2009).

42

The National Health Service Corps program provides clinicians with support, in the form of scholarships and loan forgiveness, to help meet the health care needs of individuals living in urban and rural areas where there is a lack of health care providers (HHS, 2010).

43

Medicaid reform under the ACA includes an increase in Medicaid reimbursement rates, to the level that is provided for Medicare. However, the increase may only last 2 years (see http://www​.kaiserhealthnews​.org/Stories/2010​/April/06/Medicaid-Expansion-And-Payment-Increase-Causes-Mixed-Feelings-For-MDs.aspx [accessed March 3, 2011]).

44

In risk-adjusted reimbursement, provider payment is based on patient risk and need to properly compensate for estimated work load. It is designed to remove volume from the payment equation and reward providers who achieve desired outcomes in quality, cost, and patient experience with a risk-adjusted bonus (see http://www​.medscape.com​/viewarticle/730872_6 [accessed March 3, 2011]).

45

The population of men without health insurance are likely represented in the population of men without health care visits.

46

Guaranteed issue is a requirement that a health plan enroll individuals regardless of health, age, gender, or other factors that might predict the use of health services.

47

Public Health Service Act Section 340B limits the cost of covered outpatient drugs to certain federal grantees, federally-qualified health center look-alikes, and qualified disproportionate share hospitals. Participation in the program results in significant savings estimated to be 20 percent to 50 percent on the cost of pharmaceuticals for safety-net providers (HRSA, 2011).

48

Established as part of the ACA, the Prevention and Public Health Fund is a 10-year $15 billion commitment designed to help create the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe. Among other things, this new initiative will increase the national investment in prevention and public health by, for example, supporting preventive health services such as smoking cessation, exercise programs, and other efforts to reduce the burden of chronic diseases.

49

See http://www​.healthcare​.gov/news/factsheets​/primarycareworkforce.html (accessed March 15, 2011).

50

One example is the CDC National Prevention Information Network, which contains a list of HIV/AIDS counseling, testing, and referral resources (see http://www​.cdcnpin.org/scripts/hiv/ctr​.asp [accessed March 3, 2011]).