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HIV-Experienced Clinician Workforce Capacity:
Urban-Rural Disparities in the US South
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CID April 15 2020
"HIV-experienced clinicians disproportionately practice in metropolitan areas, resulting in
significant disparities in HIV-experienced clinician workforce capacity in rural versus urban
communities. Less than a third of clinicians who provide routine HIV care are HIV-experienced,
and over 80% of counties across the South lack an HIV-experienced clinician.
Findings highlight geographic barriers to, and disparities in, access to care. Across 14
states, over 20,000 PLWH live in rural counties with no HIV-experienced clinicians and nearly
7,000 live in rural counties with no HIV clinicians at all; these PLWH may lack access to high quality HIV care in their communities. This raises concerns as limited geographic access to care
appears associated with poorer linkage to care, retention in care, and viral suppression [23, 24].
While the majority of PLWH live in urban counties, the more limited HIV clinician workforce
capacity in rural areas may ultimately contribute to the observed urban-rural disparities in HIV
care continuum outcomes [10, 14]. Moreover, as the ongoing opioid epidemic leads to new cases
of HIV and hepatitis C in rural communities [25], improving the capacity of clinicians
experienced in infectious disease management in rural areas is essential."
Rose S. Bono,1 Bassam Dahman,1 Lindsay M. Sabik,2 Lauren E. Yerkes,3,4 Yangyang Deng,1 Faye Z. Belgrave,5 Daniel E. Nixon,6 Anne G. Rhodes,4 April D. Kimmel1
1 Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond,
VA, USA 2 Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA 3 Division of Population Health Data, Virginia Department of Health, Richmond, VA, USA 4 Division of Disease Prevention, Virginia Department of Health, Richmond, VA, USA 5 Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA 6 Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth
University, Richmond, VA, USA
Abstract
Background
HIV-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the US South.
Methods
We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract (MAX) and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013) and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed clinicians accepting Medicaid approximated the region’s HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥10 Medicaid enrollees over three years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences.
Results
We identified n=5,012 clinicians providing routine HIV management, of whom 28% were HIV-experienced.
HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, p<0.001) and practice in urban areas (96% vs 83%, p<0.001) compared to non-HIV-experienced clinicians.
The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range 38.0)), with no significant urban-rural differences.
When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1,000 diagnosed HIV cases (p<0.001).
Of all identified HIV clinicians, fewer than 30% are considered HIV-experienced. HIV-experienced
clinicians are significantly less likely to practice in rural counties (4%) versus non-
HIV-experienced clinicians (17%, p<0.001). There are no significant differences by gender or
credential between HIV-experienced and non-HIV-experienced clinicians, though there are
differences by state (p<0.001). Nearly half of all HIV-experienced physicians specialize in
infectious diseases, compared to 6% among non-HIV-experienced physicians (p<0.001).
Conclusions
Significant urban-rural disparities exist in HIV-experienced workforce capacity for Southern US communities. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.
To identify adults receiving routine HIV care and their clinicians, we used administrative
claims data from the Medicaid Analytic eXtract (MAX) for adults aged 19-64 years in 14
Southern states including the District of Columbia (DC), 2009-2011. These states include some
of the highest rates of newly diagnosed HIV cases nationally [2].
Workforce Capacity
Of 926 counties assessed, over 40% (n=373) have no HIV clinicians. Counties with no
HIV clinicians have an estimated 11,987 diagnosed HIV cases, with nearly 60% in rural
counties. Across all counties, the median county-level HIV clinician-to-population ratio is 13.3
(IQR 38.0) HIV clinicians per 1,000 diagnosed HIV cases (Table 2). Ratios vary widely across
states, with medians as low as 0 in Arkansas, Kentucky and West Virginia and as high as 34.5 in
Delaware (IQR 14.5). Overall and within states, rural counties have lower workforce capacity,
with overall median clinician-to-population ratios of 7.4 (IQR 43.5) versus 16.0 (IQR 32.3) for
urban counties; however, these urban-rural differences are not statistically significant with the
exception of West Virginia (p<0.01).
Considering the n=1,397 HIV-experienced clinicians, 81% of counties have no HIVexperienced
clinicians, with rural counties less likely to have HIV-experienced clinicians (94%)
than urban counties (65%, p<0.001; Figure 2). Nearly 43,000 people diagnosed with HIV live in
counties with no HIV-experienced clinicians, and 47% of these individuals live in rural counties.
There is a median of 0 (IQR 0) HIV-experienced clinicians per 1,000 diagnosed HIV cases
across all counties. Overall and in each state except Maryland, ratios are significantly different in
rural counties and in urban counties (ps<0.05).
Introduction
Achieving national targets for people living with HIV (PLWH), promoting health equity,
and ending the United States’ (US) HIV epidemic by 2030 [1, 2] requires renewed efforts to
provide accessible, high-quality HIV care. Critical to this effort is a robust and experienced HIV
clinician workforce, since greater clinician experience in managing HIV is associated with
improved clinical outcomes for PLWH, including viral suppression [3, 4]. However, a significant
shortage in HIV care clinicians is anticipated [5, 6]; HIV medical organizations report challenges
with physician recruitment and retention [7]; and infectious disease fellowship training slots, a
key source for future HIV clinicians, are not being filled [8].
Compounding concerns about HIV clinician supply and experience, questions remain
about geographic equity in accessing HIV clinical care. The majority of HIV clinicians currently
practice or plan to practice in urban areas [5, 9], mirroring the historic urban concentration of
HIV cases. Simultaneously, the epidemic is increasingly shifting toward nonurban areas [10].
PLWH in rural areas experience more limited geographic access to HIV care [11, 12], more
advanced HIV disease at diagnosis [13], lower retention in HIV care, and lower rates of viral
suppression, compared to those living in the most urban communities [14].
Accessibility of experienced HIV clinicians in rural areas is critical to promote access to
care and improve health equity for all PLWH. Leveraging comprehensive administrative claims
data from 14 Southern states, we examined urban-rural disparities in HIV clinician workforce
capacity, particularly among HIV-experienced clinicians.
Discussion
HIV-experienced clinicians disproportionately practice in metropolitan areas, resulting in
significant disparities in HIV-experienced clinician workforce capacity in rural versus urban
communities. Less than a third of clinicians who provide routine HIV care are HIV-experienced,
and over 80% of counties across the South lack an HIV-experienced clinician.
Findings highlight geographic barriers to, and disparities in, access to care. Across 14
states, over 20,000 PLWH live in rural counties with no HIV-experienced clinicians and nearly
7,000 live in rural counties with no HIV clinicians at all; these PLWH may lack access to highquality
HIV care in their communities. This raises concerns as limited geographic access to care
appears associated with poorer linkage to care, retention in care, and viral suppression [23, 24].
While the majority of PLWH live in urban counties, the more limited HIV clinician workforce
capacity in rural areas may ultimately contribute to the observed urban-rural disparities in HIV
care continuum outcomes [10, 14]. Moreover, as the ongoing opioid epidemic leads to new cases
of HIV and hepatitis C in rural communities [25], improving the capacity of clinicians
experienced in infectious disease management in rural areas is essential.
This study underscores the limited capacity of HIV-experienced clinicians in both rural
and urban communities. Using our conservative baseline definition of HIV-experienced
clinicians, we identified a pressing gap in service accessibility particularly for rural areas. The
more restrictive definition of HIV-experienced clinicians in sensitivity analysis additionally
emphasizes limited availability in urban communities, where workforce capacity is similar to
that of rural communities in some states. A strong body of literature suggests more experienced
HIV clinicians deliver higher quality care: physicians with fewer HIV patients are less likely to
prescribe ART [26, 27], while clinicians with higher caseloads (e.g., ≥20 or 50 patients with
HIV) are more likely to meet key quality metrics for visit frequency or retention in care, CD4
cell count and HIV RNA viral load testing, viral suppression [3, 4] and certain preventive care
measures (e.g., tuberculosis testing; lipid panels) [3]. HIV caseload may be more important than
physician specialty in predicting quality of care [28], which highlights the implications of limited
HIV-experienced clinician capacity, including urban-rural disparities, for achieving national
health equity goals and ending the epidemic.
Results are broadly consistent with, yet provide a novel contribution to, the HIV
workforce literature. Across the same 14 states we studied, Gilman et al. identified a very similar
number of HIV clinicians (n=1,484) providing care to ≥10 PLWH in a year [5] as did our
analysis at baseline (n=1,397) and when relaxing the definition of routine HIV care used to
identify clinicians in sensitivity analysis (n=1,454). Our work identified a similar fraction of
HIV-experienced clinicians practicing in rural areas (4%) as the previous study (3%) [5]. In a
recent survey, 80% of HIV clinicians were physicians and 43% were women [29], compared to
82% physicians and 35% women in our sample. Building on previous work, this study is the first
to our knowledge to provide a fine-grained analysis of the geographic structure of the US HIV
workforce and to quantify urban-rural disparities in HIV workforce capacity, including among
HIV-experienced clinicians. Finally, previous analyses relied on a national probability sample of
HIV clinicians [29] or on a proprietary all-payer administrative claims database supplemented by
surveys to identify a sample of HIV clinicians [5]; this study demonstrates that using Medicaid
administrative claims alone yields similar results.
Several approaches exist to increase rural access to experienced HIV clinicians. Remote
telehealth alternatives may increase access to care for rural PLWH, with some evaluations
indicating high uptake and acceptability [30] and improvements in viral suppression [31],
although barriers such as state-specific clinician licensure, limited reimbursement for
telemedicine, and limitations on prescribing via telemedicine may hinder widespread
implementation of telehealth for HIV management [32]. Another alternative is to expand the
HIV care capacity of the existing rural clinician workforce. Programs such as the AIDS
Education and Training Centers provide training in HIV management [33, 34], but participation
may need to be expanded for clinicians to meet the needs of rural PLWH. State-level policy
efforts could involve expanding scope of practice laws for nurse practitioners, who provide HIV
care of similar quality as physicians [29, 35] but are prohibited from prescribing medications or
practicing independently in many states. Alternatively, states could employ HIV-experienced
clinicians at local health departments to provide local care or expand transportation assistance
when other solutions are not feasible.
Limitations
We used data from a single insurer (Medicaid, prior to the Affordable Care Act) so
cannot draw definitive conclusions about the total clinicians and clinician caseload or level of
HIV training. Using a single source risks underestimating the size of, and geographic disparities
within, the clinician workforce. However, findings on the size and geographic distribution of the
HIV clinician workforce are largely comparable to previous work representing different
geographic areas (e.g., state, region, national), and insurance types, including uninsurance [4, 5,
11, 12, 36]. Additionally, current Medicaid claims data are not routinely and widely available,
especially since the Affordable Care Act. However, the claims used in the current analysis, while
older, represent one of the most comprehensive sources of administrative data for the largest
insurer of PLWH and provide important evidence on HIV clinicians’ practice patterns. Current
and comprehensive data on Medicaid clinicians-including their characteristics, patient volume,
and service locations-are also not routinely available. While current and historical clinician
data from other sources are accessible (e.g., American Medical Association Physician
Masterfile), we used the older Medicaid Provider Characteristics file to remain contemporaneous
with our enrollee-level claims data and because the clinician data included additional information
(e.g., data on advanced practitioners, clinicians practicing in multiple states) not typically
available in other data sources. Given recent challenges in HIV workforce recruitment and
retention and an increasing rural epidemic, we expect that our estimates represent a conservative
upper bound of HIV workforce capacity and urban-rural disparities. Third, assigning HIV
clinicians to a single county does not capture PLWH who cross county boundaries for care or
clinicians who practice in multiple counties. Our analysis thus may overestimate the number of
counties with zero HIV clinicians and underestimate HIV clinician-to-population ratios. Yet our
assignment of HIV clinicians to a single geographic unit (here, the county) is consistent with
similar literature on US clinician workforce capacity that relies on clinician-to-population ratios
[37, 38]. Further, findings from the current study complement emerging evidence on geographic
access to HIV care suggesting increased availability of, and shorter travel to, HIV care, in urban
areas [11, 12, 36]. Fourth, the data draw on the National Plan and Provider Enumeration System,
a self-report database which clinicians may not regularly update [39], although this source
provides the most accurate physician contact information [40]. Finally, we used data from states
in a single geographic region, the US South. These states include those with the highest rates of
newly diagnosed HIV cases nationally, highlighting the importance of an adequate HIV
workforce for those newly diagnosed and diagnosed but uncontrolled. While the rural HIV
epidemic is disproportionately represented in the South, we anticipate our main findings
regarding the limited HIV workforce capacity in rural areas would generalize to other regions
[5].
Conclusions
As the US strives to end the HIV epidemic, structural barriers-including clinician
workforce capacity-and resulting disparities in access to care have emerged as critical areas of
focus. Addressing the needs of rural PLWH has become increasingly important given the shift of
the epidemic toward rural communities. HIV-experienced clinicians are more likely to practice
in urban areas, and significant urban-rural differences exist in county-level HIV-experienced
clinician workforce capacity. However, findings also suggest striking gaps in the workforce
capacity of HIV-experienced clinicians across both urban and rural locales. Policies that promote
a robust and experienced HIV clinician workforce for PLWH, whether in urban or rural
communities, are urgently needed.
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