National HIV Residency Pathway Consortium Toolkit | AIDS Education and Training Centers National Coordinating Resource Center (AETC NCRC)

Publish date:

May 06, 2024

AETC Source

The National HIV Residency Pathway Consortium (NHRPC) has developed this toolkit to make available high-quality, vetted resources for organizations interested in establishing and/or strengthening HIV pathway residency programs.

Rationale

The HIV workforce is shrinking.
The number of people with HIV in the United States is growing.
Data suggests that expanding HIV residency slots for internal medicine and family medicine trainees would be well-received.
There are excellent existing models and resources for HIV residency programs.

The combination of a shrinking HIV healthcare workforce and a growing number of people with HIV in the United States and its territories (U.S.) has led to a critical need for new strategies to train physicians and other health care providers to care for this population. Given the shift from the management of complex antiretroviral therapy (ART) regimens and opportunistic infections to primary care and chronic conditions, one logical approach to the HIV clinician shortage is to train more primary care HIV specialists by developing HIV training pathways in primary care [Family Medicine (FM) and Internal Medicine (IM)] residency training programs. Data from Budak et al¹ suggest that this is a highly effective way of expanding the workforce, showing nearly 40% of such HIV pathway graduates provide primary care to people with HIV. Moreover, data from a survey of IM and FM residency directors indicate that HIV curricular expansion would be well-received, with almost half reporting that HIV training was a high priority and 80% reporting a need to modify their existing HIV curriculum².

The goal of this toolkit is to leverage the success of existing HIV pathways to expand their number and reach, particularly in areas disproportionately impacted by HIV as identified in the federal Ending the HIV Epidemic in the U.S. (EHE) initiative. The toolkit provides minimum standards and suggested practices in HIV education for internal and family medicine HIV pathway residents in the form of curricula, competencies, clinical requirements, supervision and evaluation methods. It also highlights, and provides links to, key resources that are commonly used by training pathway faculty and residents (see Appendix A).

Caveats

The toolkit provides recommendations for minimum standards and suggested practices in HIV education for internal and family medicine HIV pathway residents, these are not requirements.
The toolkit does not replace your existing curriculum or provide the local context needed to respond to the specific needs of the community served by your residency.
It is not necessary to have all the suggested components in place from the very beginning to have a successful training track; like all of curriculum development, this is a process and it may take time to build as you go.

Needs assessment/resource analysis

Do you have the need and infrastructure to start a pathway? In order to have a successful pathway, you will need:

A minimum number of patients with HIV (see Developing Curriculum: Clinical Content) who are willing/interested in supporting the educational goals of the program with the supervision of a Family Medicine, Internal Medicine, or Infectious Disease-trained HIV specialist.
Interested residents
HIV specialist faculty
Support/buy-in from residency leadership
Experience from faculty at successful programs suggests that the likelihood of success of the pathway increases if you have:
- Pathway champion(s) – likely to be a faculty member who is able to take on the pathway director leadership role
- A sustainable network of personnel and systems to facilitate the program each year

Staffing

Suggested/ideal personnel and job description and ideal full-time equivalency (FTE):

Program director/HIV specialist

This individual’s role is to plan and implement the HIV pathway in collaboration with the institutional residency or fellowship program director. They will be responsible for the curriculum development and delivery, recruitment of trainees and their mentorship and evaluation of the program. They also oversee the schedule of the trainees to ensure they are receiving the appropriate learning experience and supervision in order to achieve their expected milestones. The minimum recommended FTE is 10%.

HIV specialist clinician(s)

One to two HIV specialist clinicians to provide additional clinical supervision and mentoring is recommended when the total number of trainees exceeds three. The clinician FTE support is not mandatory since the trainees will be working with the clinician in their already FTE-allocated clinic sessions. The program director might consider offering an annual honorarium or stipend for CME activities to the HIV clinicians.

Administrative support

One administrative assistant/program coordinator is highly recommended for the success of the HIV pathway. Their role is to work closely with the program director to schedule and coordinate all the trainees’ educational activities and clinic sessions. In addition, they can schedule meetings, keep agendas and minutes and develop recruitment materials including website/webpage. They keep track of the clinical sessions, patient panel, and evaluation process, order supplies and educational materials and process charges related to the HIV pathway. The minimum recommended FTE support is 25%.

See Appendix G for a sample budget to support the recommended staffing.

Start with specific pathway goals and objectives - “Begin with the end in mind.”

It is helpful to have clear, written goals and objectives for the training pathway as these will inform all subsequent decisions.

See Appendix B for examples from other programs.

Training models

Specialty based: some/all of pathway residents’ continuity clinics take place at affiliated HIV specialty clinics
- Examples: Emory (IM), Pitt (FM), Lancaster (FM), Yale (IM)
Primary care based: Residents are assigned patients in their continuity panel, which are scheduled into their regular continuity clinic panel sessions
- Examples: Beth Israel Deaconess Medical Center Boston (IM)
Blended model: Residents are assigned patients in their continuity panel, which are scheduled into their regular continuity clinic panel sessions, and supplement these experiences with HIV specialty clinics
- Examples: Lawrence Family Medicine Residency (FM)

Program scale and scope

Determine how many residents your program can accommodate:

Will depend on number of faculty, patients and residents. For example, some programs deliberately state a preference for residents who do not plan to do an Infectious Disease (ID)-or any other-fellowship post-residency, while others do not.

Some pathways have a separate National Resident Matching Program (NRMP)-based match, others have an application process either before residency starts or during residency.

Determine how many years of participation in the pathway are required:

In our experience, an ideal program length is 2-3 years to obtain the clinical experience necessary to achieve competency as an HIV specialist physician.

All pathway residents should complete the National HIV Curriculum.
- This comprehensive self-guided curriculum provides learners with the fundamental knowledge base required for all HIV primary care physicians
- Learning hours logged on the site can be used toward the AAHVIM Specialist certification exam requirements
- Pathway directors can create learning groups to track their learners’ progress through the curriculum
Individual programs may choose to supplement this with additional didactic activities, case conferences, journal clubs, etc.
- See Appendix C for examples of supplemental curricula from other programs

Clinical training in outpatient HIV care is central to the entire pathway experience. For new pathways, issues to address ahead of time include:

What type of outpatient clinical experience you will be able to provide; this will depend on the clinic structure/setting as noted above
How to develop resident patient panels, including panel size and selection

Patients with HIV volume targets

According to both the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA), HIV specialists should be able to demonstrate that they have provided direct outpatient care to at least 25 people with HIV over the previous 36 months.³

Notes from the field

What do these numbers mean exactly? The wording is sufficiently vague to leave it open to interpretation. The strictest interpretation would mean that the trainee needs to be the primary care physician (PCP) or HIV specialist of record for at least 25 people over the previous 36 month. But what about the following examples of potentially educationally rich clinical experiences?

People with HIV admitted to the hospital?
Providing outpatient cross-coverage for fellow residents or even faculty/attendings?
Patients who come and go from your panel; what if they leave after you’ve only seen them once?
High-volume clinics where clinicians see hundreds of patients, but not necessarily the same ones twice (eg, many clinics outside the U.S.)?

Our interpretation: this number was created with a goal to ensure that trainees have adequate experience caring for persons with HIV over time - so that they get the needed experience to provide care at all steps along the care continuum, from diagnosis to disclosure, ART and OI management, acute and chronic primary care, etc. To achieve this goal, we recommend that trainees provide direct care for a total cohort of at least 20-25 patients over a 36-month period.

Providing adequate longitudinal experience for residents

Continuity panels: it is recommended to have a minimum of 10-15 patients with HIV in the continuity panel of each pathway resident. If your clinic does not have enough patients to support this, you can consider:
- Re-evaluating how HIV patients are assigned.
- Providing “shared care,” especially if there is an HIV specialist clinician on faculty with a number of patients that would be willing to have a resident participate in their care.
- Partnering with Ryan White HIV/AIDS Program (RWHAP) clinics or other local HIV specialty clinics, including those at your partner academic medical center.
  - See Appendix A for how to locate these if you do not have existing relationships
Patient experience: Patients may develop “resident fatigue” given frequent provider turnover, so it may be helpful to rotate patients onto attending panels to give them some periods of PCP stability.

Although not always feasible, and not a strict requirement for a successful HIV pathway, the opportunity to provide inpatient care to people with HIV can be a highly valuable experience, even if that care is not directly related to their HIV. This experience can be obtained in a couple of ways:

ID consult service (especially if there is a dedicated HIV service)
“Pathways Consult Service”: HIV pathway residents could provide informal consults for every patient with a diagnosis of HIV that is admitted to the hospital on the resident service
- Residents can be empowered to make the schedule themselves.
- Residents schedule should be coordinated with the residency program director to allow inpatient HIV experience and a dedicated HIV ambulatory immersion block.

Away electives, including international electives, are options that can be highly educational for residents to see how HIV care is delivered outside their “home site,” both in terms of the challenges and the innovations.

They can also give residents exposure to specific subspecialty focus areas (eg, transgender care, high-resolution anoscopy clinics, etc.)

Resources

International Training and Education Center for Health (I-TECH/University of Washington)
ICAP (Columbia)
Institute of Human Virology/Maryland Global Initiatives Corporation (IHV/MGIC, University of Maryland)
National Clinician Consultation Center (NCCC)

Research project: in line with Accreditation Council for Graduate Medical Education (ACGME) residency required research requirement.
CQI project: in line with ACGME residency required research requirement
Community-based project: understanding community resources, strengths, and needs is foundational for every HIV clinician; community-based projects (eg, providing support for patient Q+A sessions) can be a highly valuable means of achieving this.
Advocacy: given that the vast majority of people with HIV are from historically marginalized and vulnerable populations, using one’s position in society as a physician to advocate alongside these community members is also a recommended skill for all HIV clinicians. This can be done in ways both small (eg, advocating for gender neutral restrooms in the clinic) and big (advocating at the state and federal level for relevant policy changes).
Networking: Recommend that pathway residents join Infectious Disease Society of America's (IDSA) HIV Medicine Association (HIVMA), and American Academy of HIV Medicine (AAHIVM).
Attendance at local and national conferences (including the RWHAP Clinical Conference).

See Appendix A for links to relevant organizations/activities

What are the minimum number of required curricular activities? How can you ensure that residents are scheduled for these?

This is almost uniformly reported as the biggest challenge to a successful pathway given multiple competing demands on residents’ time
It really helps to have a dedicated scheduler or program coordinator to work on this
Also helps to have residents keep track of this to ensure they are getting the experience they need
Will need to liaise with the residency to ensure ACGME continuity clinic standards are met

Example in Appendix E

We recommend a minimum of one HIV experienced (minimum three years of HIV direct clinical care) specialist faculty to do this. If your pathway has more than three total residents, additional HIV specialist faculty may be needed.

What if you don’t have an HIV specialist on site/on faculty? Potential options:

Get one: The NHPRC can assist with connecting HIV specialists to jobs, as can the AAHIVM and IDSA’s HIVMA.
Train one: Post-residency HIV fellowships are listed on the AAHIVM and HIVMA websites, or the NHRPC or your regional AETC can help establish a means to train someone on site.
Access one:
- Use colleagues: AETC National Coordinating Resource Center (NCRC), AETC Regional Offices or on HIV Care Tools mobile app
- Participate in a local ECHO program, a telemedicine consultation and training model
- Call the NCCC warmlines and hotline for expert clinician-to-clinician consultation

Precepting tips

Precepting is easiest at an onsite HIV specialty clinic where all patients with HIV are seen; it is harder but still possible if you have an integrated primary care clinic, where patients can be seen any day at any time, even when the HIV specialist faculty may not be available.

Set up time for asynchronous precepting
Provide precepting guidelines for non-HIV specialist preceptors

There are 3 main components of assessment and evaluation for HIV pathways: process evaluation; learner assessment; and program evaluation/outcomes. These are described in more detail below.

Process evaluation

Monitor and evaluate your recruitment process
Track trainees’ patient panel number, demographics, and comorbidities
Participation in National HIV Curriculum CME
Assess website and other resources usage if applicable

Learner assessment

We recommend the use of competency-based assessment tools to monitor and evaluate resident progress.⁴

Entrustable Professional Activities (EPAs) are:
- Routine professional-life activities of physicians based on their specialty and sub-specialty
- A part of essential professional work
- Require adequate knowledge, skill, and attitudes
- Should reflect one or more competencies

HIV-specific EPAs can be used (see Appendix F) to assess a trainee’s competency in HIV care based on curricular milestones and monitored every six months throughout residency.⁵

EPAs can be modified to meet individual goals and expectations for each program

Other evaluation tools:
- Preceptor evaluations of learners based on the six areas of competency used in the residency program
- Some pathways use HIV-specific objective structured clinical exams (OSCEs)
- Consider patient satisfaction surveys of the trainees

Program evaluation/outcomes

Quality of care: Patient outcomes for those patients followed by trainees based on HAB performance measures (eg, viral suppression rate, etc.)
Satisfaction: Consider trainee satisfaction survey of the program; this could be an anonymous survey or small group discussion and feedback
Retention and pathway completion: % of trainees who completed their residency training pathway
Clinical Quality Improvement: Number of successful clinical quality improvement (CQI) projects and scholarly work conducted by trainees
Career path:
- % of graduates who passed the AAHIVM certification exam
- % of graduates who pursued a career in HIV care

One of the key components to a successful training track is ongoing professional development for its trainees. This includes but is not limited to support finding a post-residency position that enables them to put the training they have received into practice. This can be done by connecting trainees with other HIV clinicians locally, regionally, and nationally. In addition to the NHPRC, organizations such as the AAHIVM, HIVMA, the Ryan White Medical Providers Coalition, and specialty-specific interest groups (eg, the HIV and Viral Hepatitis Collaborative within the Society of Teachers of Family Medicine) can provide key connections for trainees as they cultivate their careers.

Faculty mentorship is strongly encouraged given its benefits for personal and professional growth and preventing burnout. Within the NHPRC, mentorship will be provided by creating network of participating faculty and staff from programs at all different stages of development serving diverse communities in varied geographic locations across the country. For programs early in their development, a structured mentorship program consisting of monthly meetings with faculty from more seasoned programs will be encouraged; it is expected that informal mentoring relationships will also grow and develop out of the collegial collaborations that form within the Consortium.

The sustainability plan for the HIV pathway depends mainly on the following:

Financial and academic support from the graduate medical education
Commitment of faculty and clinical sites
Applicants and trainees’ interest in HIV care
Evaluation plan to secure the success of the program

We anticipate that, by building a community of learning and a network of program directors, faculty, and graduates, participants in the NHPRC will benefit from the enhanced support, visibility, and cross-pollination of human and intellectual resources. This in turn should help promote and ensure the long-term sustainability of the pathway.