Multiple studies show better outcomes when providers managing patients have expertise in HIV (see Table 18-6). In the absence of a formally recognized subspecialty society devoted to HIV medicine, government agencies, professional societies, and academic institutions have developed definitions of HIV specialization in order to develop policies, standards, and regulations, and to monitor the quality of care provided to persons with HIV (see Table 18-7). Definitions of HIV specialists generally focus on two major areas, experience and HIV CME credits, and also require that experience be current and that knowledge be updated annually. Generally, requirements for experience in the care of patients with HIV range from 10 to 20 patient-years of experience. All definitions emphasize currency of experience and education, given the rapid pace at which HIV clinical management standards change.
Table 18-6. Resources on HIV Expertise and Patient Outcomes
Gerbert B, Moe JC, Saag MS, et al. Toward a definition of HIV expertise: a survey of experienced HIV physicians. AIDS Patient Care STDS. 2001;15:321-330.
Keitz SA, Box TL, Homan RK, Bartlett JA, Oddone EZ. Primary care for patients infected with human immunodeficiency virus: a randomized controlled trial. J Gen Intern Med. 2001;16:573-582.
Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians’
experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med. 1996;334:701-706.
Kitahata MM, Van Rompaey SE, Shields A. Physician experience in the care of persons with HIV infection is associated with earlier adoption of new antiretroviral therapy. J Acquir Immune Defic Syndr. 2000;24:106-114.
Stone VE, Mansourati FF, Poses RM, Mayer KH. Relation of physician
specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy. J Gen Intern Med. 2001;16:360-368.
Willard CL, Liljestrand P, Goldschmidt RH, Grumbach K. Is experience with human immunodeficiency virus disease related to clinical practice? A survey of rural primary care physicians. Arch Fam Med. 1999;8:502-508.
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Table 18-7. HIV Specialist Definitions
Agency Requirements
American Academy of HIV Medicine (AAHIVM)* http://www.aahivm.org/new/revised_definition.htm
Current and valid state licensure (MD, DO, PA, NP) Experience: Direct, continuous, ongoing care to at least 20
patients within the past 2 years CME: 30 hours within the past 2 years Exam: AAHIVM exam at application Association of Nurses in AIDS Care (ANAC) and HIV/AIDS Nursing
Certification Board (HANCB)
http://www.anacnet.org/certification/hancb/index.html
Certification as an Advanced HIV/AIDS Certified Registered Nurse (AACRN); there is also the HIV/AIDS Certified Registered Nurse (ACRN) for nurses not functioning in advanced practice roles
Current Registered Nurse licensure with master’s degree or higher in nursing
Experience: At least 2,000 hours of HIV/AIDS nursing experience and 3 years experience as an RN within 5 years prior to application
CME: 70 hours every 4 years Exam: HANCB exam at application California
(State law, effective January, 2004)
Demonstrated expertise in treating a condition or disease involving a complicated treatment regimen that requires ongoing monitoring of the patient’s adherence to the regimen Department of Health and Human Services Centers for Medicare and
Medicaid Services (CMS)
Factsheet on Experienced HIV/AIDS Providers*: http://www.cms.hhs.gov/states/letters/smd10699.asp
Experience: active caseload of 25 patients (rural) or 50 patients (urban) within the past 24 months, with a minimum of 12 patients within the past year.
HIV Medicine Association (HIVMA)
[HIVMA is part of the Infectious Diseases Society of America*. Click on HIVMA at: http://www.idsociety.org/ Accessed 3/04.]
Experience: Direct, continuous medical care to at least 20 patients within the past 2 years
CME: 30 hours within the past 2 years; Category I in the areas of diagnosis and treatment of HIV OR Board certification or recertification in infectious diseases within the past 36 months
Johns Hopkins University Moore Clinic Experience: 50 patients a year
CME: 50 HIV-related credits a year Chart Audits
Examination (not required) New York State Department of Health AIDS Institute*
(Click on Policy at http://www.hivguidelines.org/ for HIV Specialist Policy)
New York State licensure
Experience: Ambulatory care management of at least 20 patients a year who are receiving ART CME: 10 hours per year
AAHIVM or HIVMA qualification plus ambulatory care requirements
TennCare Tennesse
Experience: active caseload of 50 patients each seen at least twice a year
CME: 20 AIDS-related category I credits annually * Websites accessed 2/04.
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KEY POINTS
While rapid change characterizes the field of clinical HIV medicine, opportunities to stay current are available through a variety of human, written, and electronic resources. The most important step in obtaining current information is to identify local resources, including local HIV specialists and regional AIDS Education and Training Centers (AETCs). The regional AETCs offer continuing education programs, distance learning for remote geographic areas, and clinical consultation for providers in the area. The National HIV Clinical Consultation Center also provides telephone consultation to providers.
A basic textbook of HIV/AIDS medicine can provide core knowledge, but it quickly becomes outdated. Books can be supplemented with newsletters, journals, and frequently updated pocket guides. Websites post summaries of newly published journal articles as well as noteworthy information. Clinical guidelines for various aspects of care and prevention are updated regularly and are available on internet websites.
The personal digital assistant (PDA) is a new healthcare information technology that enables providers to have a wealth of clinical information at the point of care. PDAs can be used in conjunction with electronic medical records for patient management.
Numerous websites provide access to information about HIV through search engines, sites that provide listings of resources including other websites, sites that provide HIV-specific information for providers and consumers, and sites that offer CME credits for providers.
Several government agencies and professional societies have developed definitions for the HIV specialist. Two major areas of qualification are experience in clinical management of patients with HIV and completion of HIV CME credits. New clinical information must be continuously integrated into the system in which care is provided. Strategies for developing and sustaining systems to support information can be implemented through individual actions and through quality improvement programs.
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