Who is an Experienced HIV Care Provider?

[Guest guest]

Dear All,

[Questions such as who is an ‘experienced HIV care provider’ and what are the

‘essential qualifications of an HIV care provider’ is increasingly becoming a

valid concern in India. It may be a worthwhile for the key stake holders

dialogue particularly with Indian Medical Association (IMA), Association of

Indian Medical colleagues and with ICMR on developing a 'quality assurance'

process of HIV care providers to ensure that the consumers are receiving quality

HIV care. Similarly a discussion on quality of HIV counselling also needs to be

addressed. Probably, all this should be carried out under a strategic HIV/AIDS

Human Resource Needs assessment. Moderator]

Definitions of an " Experienced HIV Provider " (Collected by the HIV Quality Care

Network)

The HIV Quality Care Network and its Center for HIV Quality Care

collected the following definitions. Please call, fax or e-mail the

Network with your examples.

Example 1: HIV Medicine Association

Qualifications for Physicians Who Care for

Patients with HIV Infection

Background

The onslaught of the HIV/AIDS epidemic in the early 1980s brought

with it major challenges to the nation's health care system. In

those early years, internists and family practice physicians and

others from a variety of medical disciplines joined those with

specialized training in infectious diseases to use the limited tools

then available in medicine to care for individuals with HIV disease.

Many of these physicians from the ranks of general medicine remain

leaders in the clinical care of people living with HIV disease. Any

effort to identify and/or credential physicians who are experts in

the treatment of HIV disease must acknowledge the historical and

ongoing contributions of these physicians as well as those who come

from the specialty ranks of infectious diseases.

In the last five years dramatic progress has been made in the

development of treatments to extend health and life for people with

HIV disease. Scientific and medical developments have made treating

HIV disease vastly more sophisticated and complex than it once was.

Physician education and training related to new developments in the

field and ongoing experience working with patients with HIV disease

are essential to ensure that these patients get optimal care. The

changing health care system, with its myriad delivery and financing

mechanisms, has highlighted the importance of access to specialized

care.

The HIV Medicine Association (HIVMA) of the Infectious Diseases

Society of America (IDSA) offers the following guidance to public and

private health care payors and institutions to identify and recruit

health care professionals with expertise in HIV disease. Our goal is

to assist these organizations in ensuring that patients with HIV

disease receive the highest quality of care that reflects the most

current medical research at the hands of those who have demonstrated

experience and commitment to treating this disease. The guidance we

offer is intended to allow flexibility, based on the special

circumstances of any given community or institution relative to the

prevalence of HIV disease and the availability of physicians to treat

patients with HIV disease. In addition, this guidance may be viewed

and implemented in the context of existing state or other

institutional guidelines related to continuing medical education.

Qualifications

HIVMA believes that an HIV-qualified physician should manage the care

of patients with HIV disease. There is ample evidence in the

research literature that care by experienced HIV providers translates

into improved clinical outcomes. In defining HIV-qualified

physicians, one must take into account both the training and

expertise of infectious disease specialists and pediatric infectious

diseases specialists, as well as the expertise and experience of

physicians from a variety of medical disciplines who have made a

significant professional commitment to HIV/AIDS care and who care for

tens of thousands of patients with HIV disease.

We propose that any credentialing process to identify HIV- qualified

physicians be based on a combination of patient experience and the

demonstration of ongoing education and training in HIV care,

especially in the area of antiretroviral therapy. To be an HIV-

qualified physician, an individual should be able to show continuous

professional development by meeting the following qualifications:

In the immediately preceding 24 months has provided continuous and

direct medical care to a minimum of 20 patients who are infected with

HIV; and

In the immediately preceding 24 months has successfully completed a

minimum of 30 hours of Category 1 continuing medical education in the

diagnosis and treatment of HIV-infected patients; or

In the immediately preceding 36 months has obtained board

certification or recertification in the field of infectious diseases.

Recently trained infectious diseases (ID) fellows or those recently

certified or recertified in infectious diseases should be considered

qualified providers of patients with HIV/AIDS. However, given the

rapid pace of change in HIV medicine, board certification in

infectious diseases and pediatric infectious diseases does not

guarantee sufficient knowledge to assure that an ID specialist will

remain an expert in HIV disease over time. Therefore, all physicians

(including ID and pediatric ID physicians) should meet the experience

and education based criteria outlined above to retain their HIV-

qualified status.

Relationship between HIV Provider Experience and

Patient Outcomes

Selected References

AIDS mortality rates lower at sites with HIV experience. AIDS Alert

1999:14(11): 129-30.

Bach PB, Calhoun EA, CL. The relation between physician

experience and patterns of care for patients with AIDS-related

Pneumocystis carnii pneumonia: results from a survey of 1,500

physicians in the United States. Chest 1999; 115(6): 1563-9.

Brosgart C et al. Community patterns of care for HIV disease:

experience makes a difference. Int Conf AIDS 1998; 12:1143-44.

Brosgart CL et al. Clinical experience and choice of drug therapy

for human immunodeficiency virus disease. Clin Infect Dis 1999; 28

(1): 14-22.

Hecht FM et al. Optimizing care for persons with HIV infection.

Society of General Internal Medicine AIDS Task Force. Ann Intern Med

1999; 131(2): 136-43.

Kitahata MM, Van Rompaey SE, Shields AW. Physician experience in the

care of HIV-infected persons is associated with earlier adoption of

new antiretroviral therapy. J Acquir Immune Defic Syndr 2000; 24(2):

106-14.

Kitahata MM et al. Physicians experience with the acquired

immunodeficiency syndrome as a factor in patients' survival. NEJM

1996; 334(11): 701-706.

Laine C et al. The relationship of clinic experience with advanced

HIV and survival of women. AIDS 1998; 12(4): 417-424.

Markson LE et al. Repeated emergency department use by HIV-infected

persons: effect of clinic accessibility and expertise in HIV care.

J Acquir Immune Defic Syndr & Human Retrovirology 1998; 17(1): 35-41.

Shapiro M et al. Variations in the care of HIV-infected adults in the

United States. JAMA 1999; 281:2305-2315.

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 of Fam

Med 1999; 8(6): 502-8.

Example 2: Excerpted from October 6, 1999, HCFA letter to State

Medicaid Directors from Block, Deputy Administrator, Center

for Medicaid and State Operations

Definition of an Experienced HIV/AIDS Provider: An experienced

HIV/AIDS provider is a licensed physician, nurse practitioner, or

physician assistant who has maintained an active HIV/AIDS medical

practice by providing continuous and direct medical care to a minimum

number of individuals and has completed a minimum number of hours of

continuing medical education on topics related to the care and

management of individuals with HIV/AIDS.

Experts recommend an active ongoing caseload of at least 25

individuals with HIV/AIDS over the preceding 24 months, either in

regular practice or as part of a supervised post-graduate training

program. In urban areas with high incidence this should be a minimum

of 50 patients over the preceding 24 months. Experts in the HIV/AIDS

field further suggest 12 as the minimum number over a 1-year period.

Example 3: Sample Purchasing Specifications for HIV Infection, AIDS,

and HIV-Related Conditions, prepared by the Center for Health

Services Research and Policy at the Washington University

School of Public Health and Health Services with support from the

Centers for Disease Control and Prevention and the Health Resources

and Services Administration.

(e) Experienced HIV provider57- a license physician, nurse

practitioner, or physician assistant who has:

Maintained an active HIV/AIDS medical practice by providing

continuous an direct medical care to at least ___ individuals with a

full spectrum of HIV/AIDS; and

Has completed at least __ hours of continuing medical education on

topics related to the care and management of individuals with

HIV/AIDS.58

Example 4: HIV SPECIALIST POLICY

New York AIDS Institute (revised February 2000)

The complexity of the ambulatory care management of people with HIV

in the year 2000, especially with regard to the use of antiretroviral

therapy, has necessitated a corresponding increase in the level of

expertise of clinicians providing this care. In the absence of formal

criteria to certify and license clinicians as HIV specialists,

agencies in the medical and public health sectors have forged ahead

to develop local definitions to govern their operations and above all

to foster the highest quality of care for people with HIV. The intent

of this policy is to guide clinical providers and health care

facilities in development and implementation of their own procedures

for the licensing and credentialing of HIV specialists and to

articulate the standard for a statewide definition of an HIV

Specialist.

Considerable deliberation by the Medical Care Criteria Committee

resulted in a general consensus of opinion regarding the need for an

experience-driven definition of an HIV Specialist, and for a

description of mechanisms by which individual providers who lack the

required level of experience might gain it. The Committee also

encourages all HIV practitioners to honestly assess their own levels

of experience in order to best define their appropriate status.

Introduction

The clinical care of persons with HIV/AIDS requires the participation

of physicians with specialized expertise in the practice of HIV

medicine.

Scientific and clinical knowledge about the management of HIV

infection and disease continues to evolve at a rapid pace, resulting

in frequent changes in state-of-the-art practice. As diagnostic and

therapeutic advances occur and as evidence mounts to support specific

management strategies, they must be integrated into routine care as

quickly as they are known to become available to persons living with

HIV.

Qualifications for HIV Specialist Status

The single most important factor in gaining experience in HIV

clinical management is through direct hands-on experience including

the direct management of antiretroviral therapy. The following

criteria define an HIV Specialist:

Direct clinical management of persons with HIV as part of an ongoing

fellowship, private practice, or clinic or hospital-based practice

during the last two years. This includes primary ambulatory care of

HIV-infected patients including the management of patients receiving

antiretroviral therapy over an extended period of time. This

experience should equal twenty patient-years of experience. Twenty

patient-years of experience could be obtained, for example, by seeing

40 unique patients over a period of six months, 20 unique patients

over a period of one year, or 10 unique patients over the course of

two years.

And

Six hours annually of CME that includes information on the use

antiretroviral therapy in the ambulatory care setting.

In accordance with Public Health Law (cite) nurse practitioners who

provide clinical care to HIV-infected individuals in collaboration

with an HIV specialist physician may also be considered HIV

Specialists. Physician assistants and certified nurse-midwives who

provide clinical care to HIV-infected individuals under an HIV

specialist physician1s supervision may also be considered HIV

Specialists.

Expectations of an HIV Specialist

An HIV specialist should have an understanding of the following areas:

Latest information about HIV disease and treatments. Advances in

antiretroviral therapy continue to make HIV a dynamic field. Data

regarding new drugs and their combinations continue to emerge,

changing standards of practice. Familiarity with these new drugs,

their side effects, and interactions with other drugs is a feature of

basic HIV care.

State of the art diagnostic techniques, including quantitative viral

measures and resistance testing.

Immune system monitoring. Strategies to promote treatment adherence,

including methods to elicit information about adherence from patients

as well as techniques to measure adherence in clinical practice and

referral sources for adherence support services.

Management of opportunistic infections and diseases. Basic

familiarity with the clinical presentation and proper diagnostic

approach to opportunistic diseases and a strong grasp of the

therapeutic strategies to manage them is an essential part of basic

HIV care. New pathogens are recognized as the cause of HIV-related

infections that are treated with specific drugs with which the

physician must be familiar.

Expertise in the management (including appropriate referral) of HIV-

infected patients suffering from commonly-associated comorbid

conditions, including tuberculosis, hepatitis B and C, syphilis and

treatment-related lipid disorders.

Early recognition of organ system manifestations of disease. Clinical

experience with management of HIV disease is the only determinant of

skill in HIV diagnostics.

Importance of access to clinical trials, and how to refer to them.

Post-exposure prophylaxis protocols and infection control issues.

Care Coordination. Proper referral to other providers for specialty

care (e.g.,: oral, ophthalmologic, obstetrics, gynecology,

dermatology, nutrition, drug treatment)

Patient education, including risk reduction/harm reduction counseling.

How Can Clinicians Gain the Necessary Experience?

Several acceptable methods of gaining experience in ambulatory

management of people with HIV exist including mini-residencies,

participation in a fellowship, co-management of patients with an HIV

specialist and education from an authorized CEI clinical provider. A

signed verification of the number of person-hours of management in

these units should be obtained.

How Often Should HIV Specialists be re-credentialed?

Clinicians should be reassessed every two years to determine whether

they continue to meet the criteria for HIV Specialist status.

Example 5: s Hopkins Options Program, s Hopkins School

of Medicine, Baltimore HIV/AIDS medical program with a Medicaid

contract with the state of land

HIV physician must manage at least 50 HIV patients a year, take 50

HIV-related CME credits annually, and be subject to periodic chart

audits.

Example 6: American Board of Internal Medicine

Persons trained in infectious diseases are considered experts in

treating HIV disease if they are certified in the subspecialty of

Infectious Diseases.

Example 7: Tennessee Medicaid Program -- TennCare

Criteria for HIV physicians in the AIDS Centers of Excellence -- an

actively managed base of at least 50 HIV positive patients, each

being seen at least twice a year, and at least 20 new CME/CEU

category I credits per year in AIDS related care

Example 8: Arizona Medicaid program--Arizona Health Care Cost

Containment System (AHCCS)

AHCCCS offers plans a supplemental reimbursement for members on

protease inhibitors, but they must be under the care of a qualified

HIV/AIDS treatment professional. HIV/AIDS treatment professionals are

submitted to AHCCCS and are defined as:

Known in the community to have a special interest, knowledge and

experience in the treatment of HIV/AIDS infected individuals;

Willing to adhere to defined AHCCS AIDS Advisory Committee (AAAC)

guidelines; and

Willing to provide primary care services and/or specialty care to

AHCCCS members infected with HIV/AIDS

Note: These individuals must be submitted and approved by a committee

set up by the Medicaid program called the AHCCCS AIDS Advisory

Committee (AAAC). This group is chaired by the Medicaid medical

director, has representatives from 4 health plans and at least two

experts in the treatment of HIV and AIDS infected patients. This

group reviews treatment protocols, current standards of practice and

treatment outcomes and revises Committee guidelines for HIV clinical

treatment protocols and pharmaceutical regimens, in addition to

approving the lists of HIV experts submitted by each health plan.

Example 9: California State Law Regulating Private And Medicaid

Health Plans--Assembly Bill No. 2168--Amendment to the California

Health and Safety Code

Beginning January, 2001 a new law in California will require managed

care organizations (MCOs) to provide patients with HIV infection with

standing referrals to physicians with " demonstrated expertise " in

treating HIV or AIDS. On Sept. 12, Governor Gray (D) signed a

bill that amended the state health code by adding HIV infection and

AIDS to the list of conditions requiring a standing referral to a

specialist.

Existing California law requires every health care service plan to

establish and implement a standing referral policy for an

enrollee " with a condition or disease that requires specialized

medical care over a prolonged period of time and is life-threatening,

degenerative, or disabling. " The new law would place HIV and AIDS

within this definition and define the HIV/AIDS specialty provider as

an individual " with 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. " The

determination of eligibility for a standing referral must be made

within three business days of the date of the request by the enrollee

or the enrollee's primary care physician and when all appropriate

medical records and other items necessary to make the determination

are provided. Once a determination is made, the referral shall be

made within four business days of the date of its submission to the

plan medical director or her or his designee.

The section of the law related specifically to HIV/AIDS will sunset

on January 1, 2004, or when the state, federal government or a

voluntary national health organization adopts an accreditation

process for an HIV/AIDS specialist, whichever date is earlier. The

new law covers both private and Medicaid managed care plans in the

state.

How Does Your Program Define " Experienced HIV Provider " ?

Let us know by:

Fax: 703-299-0473

E-mail: hivnetwork@...

Mail: 66 Canal Center Plaza, Suite 600

andria, VA 22314

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Source: http://www.hivma.org/HIV/HIVnet_ProDef.htm