Today in the United States, more than one million people are living with HIV and many more are at risk for infection. Now, the Trump administration is focusing on 57 high-risk counties, cities, and states as phase one of its plan to end HIV by 2030.
But there's a problem: If all the patients who need HIV services suddenly step forward, there won't be enough providers to care for them.
The HIV workforce shortage is "the elephant in the room" amid discussions of the Ending the HIV Epidemic initiative at the 2019 IDWeek meeting in Washington, D.C., said Carlos del Rio, M.D., professor and chair of the Hubert Department of Global Health at the Rollins School of Public Health at Emory University.
"The system is bursting at the seams," said Melanie Thompson, M.D., principal investigator of the AIDS Research Consortium of Atlanta. "If you don't fix that, then none of this other stuff is going to happen."
"No one does HIV care because they want to make a lot of money -- we do it because we want to help people," said Robert Goldstein, M.D., Ph.D., medical director of the Transgender Health Program at Massachusetts General Hospital in Boston. "It's a lot about the money, but also to make sure we overall recognize this is a challenging space, these are challenging patients, and we need support."
To fix the workforce shortage, Thompson and other leaders have outlined three advocacy priorities. First and foremost is to fix the broken reimbursement system that makes HIV care a less lucrative (and therefore less attractive) medical profession for the next generation of would-be clinicians.
So-called "cognitive specialties" are routinely under-compensated, explained Thompson. When it comes to payer reimbursements, medical procedures like surgeries and other hands-on interventions are far more lucrative, she said. "We have to compensate people fairly," said Wendy Armstrong, M.D., a professor of medicine at Emory University.
Thompson, who is the immediate past chair of the HIV Medicine Association, has been at the forefront of advocacy efforts on Capitol Hill to change the way Medicaid and Medicare -- two of the largest payers in the United States -- reimburse HIV care providers.
The second solution Thompson and others have proposed is to implement a debt forgiveness program for medical students who choose to specialize in HIV care -- akin to the debt forgiveness programs available for teachers who elect to work in resource-poor communities.
"Many students I see are interested in HIV care and social determinants of health and social inequities but can't afford to" specialize in HIV because of their massive student debt, Armstrong said. Passing a debt relief package would encourage a younger and more diverse cohort of medical professionals to specialize in HIV.
The third proposal is to spread the burden of HIV care beyond infectious disease specialists. That means creating opportunities for other care providers, such as nurses, physician assistants (PAs), and general practitioners to serve at-risk and HIV-positive patients, spreading the burden of HIV care across a broader swath of medical professionals.
Burnout is a very real threat to the already thin HIV workforce, said Goldstein.
"If I'm in clinic from 8 a.m. to 8 p.m. seeing patients nonstop and I don't have time to … address some of the other issues that are making it difficult for them to become virally suppressed, I'm not doing a great service to them, and I'm not going to want to do that job forever," he said.
"Making the workforce more sustainable means figuring out how to better use advanced practice providers, NPs [nurse practitioners], and PAs," Goldstein added.
"We need to engage a bigger community," said Armstrong. "We can engage a really big community to talk about PrEP. We can talk about a bigger community and have them be competent HIV doctors."
"Many of us got into HIV because we were passionate about it," del Rio said. But between burnout, low pay, and lack of resources, many would-be HIV clinicians are choosing other specialties.
"We need to figure out how to make staying here attractive," del Rio said.
And when it comes to the federal Ending the HIV Epidemic by 2030 initiative, Thompson said that fixing the HIV workforce problem "is really the lynchpin for the whole thing."