Teaching HIV to Primary Care Providers Dr Thor

Teaching HIV to Primary Care Providers Dr. Thor Swanson U of Iowa Asst. Clinical Professor of Family Medicine Siouxland Medical Educational Foundation AAHIVM HIV Specialist Spring 2009 SCHC HIV Conference, STFM Meeting

Abstract Despite early pessimism that all HIV patients were destined for early death, the advent of ART has prolonged the lives of HIV-infected patients indefinitely and now turned HIV infection into a chronic disease. In many cases, the burden of providing diagnostic, primary, and sometimes even HIV treatment care for these patients is increasingly falling on Family-practice trained physicians [and midlevels], both in North America and Africa. Ø This presentation will consider how family medicine residencies and offices can train residents and physicians [and mid-levels] to provide diagnostic, primary care, and even longitudinal treatment care to HIV patients. The presenter will share experiences (both helpful and not) in training family medicine HIV providers in northwest Iowa, USA and Kijabe, Kenya. Ø

Objectives Ø Gain an awareness of HIV/AIDS issues that affect primary care providers Ø Note ideas for how to train primary care providers in HIV medicine Ø See how HIV/AIDS training must look different in varied settings- i. e. North America vs. Africa

Thesis Ø Family Medicine has a need and a duty to adequately train providers in HIV prevention, diagnosis, primary care and treatment.

Outline- The Tasks Ø 1) Sowing the Vision: Encouraging a need to know Ø 2) Knowing with Vision: Identifying what to know Ø 3) Growing the Vision: Providing a means to know Ø 4) Showing some Vision: Sites training providers to know

Task 1: Sowing the Vision. Encouraging a need to know

Sowing Vision- Encouraging a need to know Ø The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often think they don’t need to know anything about HIV.

Sowing Vision- Encouraging a need to know Ø The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often think they don’t need to know anything about HIV. Ø The answer: They need to know at least something

Sowing Vision- Encouraging a need to know- The statistics Ø The world Ø America Ø NW Iowa

Global summary of the AIDS epidemic, December 2007 Number of people living with HIV in 2007 People newly infected with HIV in 2007 AIDS deaths in 2007 Total Adults million] Women million] Children under 15 years 33 million [30 – 36 million] 30. 8 million [28. 2 – 34. 0 15. 5 million [14. 2 – 16. 9 2. 0 million [1. 9 – 2. 3 million] Total Adults Children under 15 years 2. 7 million [2. 2 – 3. 2 million] 2. 3 million [1. 9 – 2. 8 million] 370 000 [330 000 – 410 000] Total Adults Children under 15 years 2. 0 million [1. 8 – 2. 3 million] 1. 8 million [1. 6 – 2. 1 million] 270 000 [250 000 – 290 000] 10

Sowing Vision- Encouraging a need to know Ø The epidemiology of needing to know- if anyone thinks they don’t need to know, it is providers in rural NW Iowa.

Diagnoses of HIV Infection 1 in Iowa * 1 Includes all persons reported to have tested positive for HIV while a resident of Iowa, regardless of current diagnosis (HIV or AIDS). Also includes persons who were diagnosed with AIDS while residents of Iowa but for whom residence at time of HIV diagnosis was unknown. * Data for year 2007 may be incomplete due to delays in reporting.

Sowing Vision- Encouraging a need to know Ø Some anecdotes of needing to know- 69 year old woman, 59 year-old business man, 37 year old English teacher

Sowing Vision- Encouraging a need to know Ø If we are going to educate primary care providers in HIV, they have to want to learn- (negatively) to see the need, but (positively) to see the fruits of knowing in cases found and patients treated.

Task 2: Knowing With Vision- Identifying what to know

Knowing With Vision- Identifying what to know Ø The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often have no idea what they need to know about HIV.

Knowing With Vision- Identifying what to know The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often have no idea what they need to know about HIV. Ø The answer: All primary care providers need to know something about HIV, but the extent of that knowledge is dependent upon their practice (or expected) practice setting. Ø

Knowing With Vision- Identifying what to know Ø All primary care providers need to know something about HIV, but the extent of that knowledge is dependent upon their practice (or expected practice) setting. Ø Is that setting in Africa or America or elsewhere? Ø If America, is it urban, rural or suburban; low-income or high income; high HIV prevalence or low HIV-prevalence area.

Global summary of the AIDS epidemic, December 2007 Number of people living with HIV in 2007 People newly infected with HIV in 2007 AIDS deaths in 2007 Total Adults million] Women million] Children under 15 years 33 million [30 – 36 million] 30. 8 million [28. 2 – 34. 0 15. 5 million [14. 2 – 16. 9 2. 0 million [1. 9 – 2. 3 million] Total Adults Children under 15 years 2. 7 million [2. 2 – 3. 2 million] 2. 3 million [1. 9 – 2. 8 million] 370 000 [330 000 – 410 000] Total Adults Children under 15 years 2. 0 million [1. 8 – 2. 3 million] 1. 8 million [1. 6 – 2. 1 million] 270 000 [250 000 – 290 000] 20

Regional HIV and AIDS statistics and features, 2007 Adults & children living with HIV Sub-Saharan Africa Middle East & North Africa South and South-East Asia Latin America Caribbean Eastern Europe & Central Asia Western & Central Europe North America Oceania TOTAL 22. 0 million [20. 5 – 23. 6 million] Adults & children newly infected with HIV 1. 9 million [1. 6 – 2. 1 million] Adult prevalence (15‒ 49) [%] 5. 0% Adult & child deaths due to AIDS 1. 5 million [4. 6% – 5. 4%] [1. 3 – 1. 7 million] 380 000 40 000 0. 3% 27 000 [280 000 – 510 000] [20 000 – 66 000] [0. 2% – 0. 4%] [20 000 – 35 000] 4. 2 million 330 000 0. 3% 340 000 [3. 5 – 5. 3 million] [150 000 – 590 000] [0. 2% – 0. 4%] [230 000 – 450 000] 740 000 52 000 [480 000 – 1. 1 million] [29 000 – 84 000] [<0. 1% – 0. 2%] [24 000 – 63 000] 0. 5% 63 000 [0. 4% – 0. 6%] [49 000 – 98 000] 1. 7 million 140 000 [1. 5 – 2. 1 million] [88 000 – 190 000] 0. 1% 40 000 230 000 20 000 1. 1% 14 000 [210 000 – 270 000] [16 000 – 25 000] [1. 0% – 1. 2%] [11 000 – 16 000] 1. 5 million 110 000 0. 8% 58 000 [1. 1 – 1. 9 million] [67 000 – 180 000] [0. 6% – 1. 1%] [41 000 – 88 000] 730 000 27 000 0. 3% 8000 [580 000 – 1. 0 million] [14000 – 49 000] [0. 2% – 0. 4%] [4800 – 17 000] 1. 2 million 54 000 0. 6% 23 000 [760 000 – 2. 0 million] [9600 – 130 000] [0. 4% – 1. 0%] [9100 – 55 000] 74 000 13 000 0. 4% 1000 [66 000 – 93 000] [ 12 000 – 15 000] [0. 3% – 0. 5%] [<1000 – 1400] 33 million 2. 7 million [0. 7% 0. 9%] [1. 8 – 2. 3 million] [30 – 36 million] [2. 2 – 3. 2 million] 0. 8% The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. 2. 0 million 21

Over 7400 new HIV infections a day in 2007 • More than 96% are in low and middle income countries • About 1000 are in children under 15 years of age • About 6300 are in adults aged 15 years and older of whom: — almost 50% are among women — about 45% are among young people (15 -24) 22

A global view of HIV infection 33 million people [30– 36 million] living with HIV, 2007 Figure 2. 2 2008 Report on the global AIDS epidemic

HIV prevalence (%) in adults (15– 49) in Africa, 2007 Figure 2. 8 2008 Report on the global AIDS epidemic

Diagnoses of HIV Infection 1 in Iowa * 1 Includes all persons reported to have tested positive for HIV while a resident of Iowa, regardless of current diagnosis (HIV or AIDS). Also includes persons who were diagnosed with AIDS while residents of Iowa but for whom residence at time of HIV diagnosis was unknown. * Data for year 2007 may be incomplete due to delays in reporting.

Prevalence of Diagnosed HIV and AIDS by County of Residence at Diagnosis, Persons Living on December 31, 2007 Counties with more than 6 cases State average = 52 / 100, 000 pop. Polk Scott Johnson Pottawattamie Black Hawk Woodbury Marshall Linn Henry Des Moines Wapello Clinton Page Muscatine Story Clayton Buena Vista Jackson Cerro Gordo Ten most populous counties are shown in bold. Washington Webster Dallas Dubuque Lee Warren Marion Jasper Persons living with HIV/AIDS per 100, 000 population County numbers do not include diagnoses in prisons

Knowing With Vision- Identifying what to know Ø Primary care providers not only need a vision to know (something) Ø They need to know what to know in their practice setting.

4 Levels of knowing amongst primary care providers Ø 1) Prevention of HIV Ø 2) Diagnosis of HIV Ø 3) Primary Care of patients with HIV- Providing a Medical Home******* Ø 4) Clinical Treatment of patients with HIV

Level 1 -Prevention Ø Prevention-Most primary care providers will need to work at this level. Ø Encouraging safe sex practices and preventing transmission of HIV is the opportunity and duty of every well-visit provider in America.

Level 1 -Prevention Ø Knowledge l l Transmission Facts about HIV Prevalence Statistics of Practice Area and Population

Level 1 -Prevention Ø For the primary care Ø Picture of C. Everett provider who is going Koop Edited out to work only at level 1, they need to see themselves as: Ø 1) A public health official

Level 2 -Diagnosis Ø Diagnosis-Most primary care providers will need to work at this level. Ø Being ready to work-up and diagnosis a possible HIV-infected patient with an opportunistic infection is also necessary for any provider who works in an urgent care, emergency room, outpatient office, or in-hospital services where he or she is diagnosing the ailments of sick people.

Level 2 -Diagnosis Ø Knowledge l l Transmission Facts about HIV Prevalence Statistics of Practice Area and Population Basic facts of CD 4 counts and Viral Loads Basic opportunistic infections of HIV, especially how cases present in practice area.

Level 2 -Diagnosis Ø For any patient, but especially the atypical one, the primary care provider needs to begin to think: Is HIV a reasonable part of the diagnosis of this patient?

Level 2 -Diagnosis Ø For the primary care Ø Picture of Dr. House provider who is going (Hugh Laurie) Edited to work only at level 1, Out they need to see themselves as: Ø 2) A medical detective

Level 3 -Chronic primary care provider Ø As HIV becomes a chronic disease, more and more primary care providers are needed who are willing to have HIV+ patients. Ø This could be done according to 2 models: l l 1) The primary care provider manages general issues only, and HIV treatment is managed by an HIV specialist 2) The primary care provider manages both general issues, and HIV treatment (level 4)

Level 3 - Ongoing Primary Care Ø For the primary care provider who is going to work only at level 3 or at levels 3 and 4, he or she needs to see themselves as: Ø 3) Medical Home Manager

Level 3 -Ongoing primary care Ø Picture of Primary Care Home Edited Out

Level 3 -Ongoing primary care Ø Picture of Marcus Welby MD Edited Out

Level 3 -Ongoing primary care- Dr. Sydney Hansen 1999 -2002 Ø Picture of Dr. Sydney Hansen of Providence TV show edited out.

Level 3 - Ongoing Primary Care

Level 3 -Ongoing primary care Ø Social work situations l l l Ø Spotting Immune Reconstitution Disease l Ø More diagnosis of opportunistic infections Treating chronic complications l l Ø Low-resource Co-morbid psychiatric disease Substance abuse and addiction problems Cardiovascular Disease Hepatic Disease Neuropathy Dermatology Ongoing prevention of transmission

Level 4 HIV Specialist/Treatment Manager for HIV+ patients Ø 2 Models l l 1) Primary care providers who function as HIV specialists for patients, but are not the patient’s primary care provider 2) Primary care providers who function both as primary care provider and HIV specialist for their patients.

Level 4 Treatment Provider for HIV+ patients Ø Knowledge l l l l 1) Indications to start treatment 2) Medication choices 3) Monitoring treatment long-term- CD 4, VL 4) Medication side effects 5) Resistance testing and changes 6) Long-term complications 7) Social work issues

Level 4 Treatment Provider for HIV+ patients Ø Cartoon Edited Out Ø Monogram of AAHIVM edited out.

Level 4 Treatment Provider for HIV+ patients Ø This provider will need to see themselves as a “mini-specialist” in HIV and commit themselves to operating at a “specialist” level, attending HIV meetings, reading HIV magazines, etc. . .

Level 4 Treatment Provider for HIV+ patients Ø Picture From Movie Outbreak Edited Out

4 Levels of knowing amongst primary care providers Ø 1) Prevention of HIV Ø 2) Diagnosis of HIV Ø 3) Primary Care of patients with HIV Ø 4) Clinical Treatment of patients with HIV Ø Most primary care providers need to be level 1 and 2 knowers, levels 3 and 4 are on a need-to-know, or choose-to-know basis.

Growing Vision- Providing a means to know

Growing Vision- Providing a means to know Ø We have to move providers from: point A Ø No-knowledge Ø No practice Ø No experience Ø to point B knowledge practice experience

Growing Vision- Providing a means to know Ø How can we move people from A (where they are now) to B (An HIV friendly provider at any level 1 -4)?

Growing Vision- Providing a means to know Ø Image Edited out.

Growing Vision- Providing a means to know 3 Types of Knowledge in Medical Expertise Ø Covered in Norman, Geoff; Eva, Kevin; Brooks, Lee; and Hamstra, Stan; “Expertise in Medicine and Surgery, ” pp. 339 -353, in The Cambridge Handbook of Expertise and Expert Performance, edited by K. Anders Ericsson, Neil Charness, Paul J. Feltovich, and Robert R. Hoffman. New York: Cambridge University Press, 2006. Ø Ø Visual Image of Book edited out.

Growing Vision- 3 Types of Medical Knowledge Causal Knowledge: The role of Basic Science Analytic Knowledge: The role of analysis/ diagnosis Ø Experiential Knowledge: The Role of Exemplars Ø Ø Ø Norman, Geoff et al. Expertise.

Level 1: Causal Knowledge- Role of Basic Science Causal Knowledge: The role of Basic Science (in medicine) There is basic science that needs to be mastered related to HIV Microbiology-HIV Virus, opportunistic parasites Immunology- Immune System Anatomy and Neuroanatomy- Multiple organs, especially CNS Pathology and Pathophysiology- Multiple organs, organ systems, organisms Ø Pharmacology- HIV drugs, antibiotics, drug interactions Ø Ø Ø Ø Norman, Geoff et al. Expertise.

Level 1: Causal Knowledge- Role of Basic Science Ø As I tell people, to be an HIV provider- a whole new set of causal/fromal knowledge needs to be learned or relearnedregarding HIV, microbiology, et al.

Level 2: Analytical Knowledge: signs and symptoms Ø Ø Ø Ø Analytical Knowledge: Signs and symptoms and diagnosis (in medicine) Knowledge of translating signs and symptoms into diseases and diagnoses Basic HIV including CD 4 counts, Viral Loads Opportunistic infections Immune reconstitution diseases Long-term complications Cough-PCP, TB Diarrhea- Cryptosporidium, Microspora Skin Rash- Zoster, KS Head ache- Cryptococcus, TB Meningitis Ø Norman, Geoff et al. Expertise. Ø Ø

Level 2: Analytical Knowledge: signs and symptoms Ø As I tell people, to be an HIV provider- a whole new set of analytical knowledge needs to be learned- there is a 2 nd set of differential diagnosis that has to be mastered for each presenting problem.

Level 3: Experiential Knowledge: The Role of Exemplars Experiential Knowledge: Role of Examples (in medicine) The difference between the expert and the non-expert is in this realm of experience Ø “Just as the chess master has access to about 50, 000 stored positions (Gobet and Simon, 2000), any expert has acquired her expertise in part by working through many examples that can now serve as a rich source of analogies to permit efficient problem solving. ” (p. 344) Ø “These findings suggest that it takes many examples, and not just formal knowledge, to become an expert (a finding consistent with the 10, 000 hours practice of chess masters (Simon and Chase, 1973). But there is as yet very little evidence [in medicine, my addition], how these experiences should be structured to enhance the efficiency of learning. ” (p. 345) Ø “Medical expertise explicitly involves coordination of both analytical and experiential knowledge. We are just beginning to understand the interplay between these two forms of knowledge. ” (p. 350) Ø Ø Ø Norman, Geoff et al. Expertise.

Level 3: Experiential Knowledge Ø Experiential Knowledge: The role of Basic Science (in medicine) Ø There is experience related to HIV Ø Meds and side effects Ø Diagnosis of and treatment of OIs and Immune Reconstitution Syndromes Ø Diagnosis and treatment of long-term complications

Level 3: Experiential Knowledge: Role of Exemplars Ø As I tell people, to be an HIV provider- a whole new set of experiential knowledge needs to be learned- a whole new set of experiences is needed to feel comfortable and be competent diagnosing and treating in the HIV world.

Growing Vision- Providing a means to know Ø The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often have no idea or no opportunity about how to get the training they need or desire in HIV.

Growing Vision- Providing a means to know Ø The problem: Primary Care providers including Family Medicine, Internal Medicine, and Pediatric health care people often have no idea or no opportunity about how to get the training they need or desire in HIV. Ø The answer: There are many modalities that have been shown to work in my education sites and elsewhere.

Methods Utilized- Causal/Formal Knowledge and Analytical Knowledge Readings- Journals- CID*, Articles- off Pub. Med*, Textbooks- AAHIVM Fundamentals*, AIDS Therapy, Hopkins Medical Magament of AI Ø Websites- UCSF*, Johns Hopkins*, MATEC* Ø Local lectures- AIC Kijabe weekly conference, SCHC monthly HIV conference, SMEF residency lectures and teaching rounds Ø Courses- UCSF*, MATEC*, Harvard Ø

SCHC HIV Conference • • • 30 August 2007: Interesting HIV Cases from Africa 27 September 2007: Interesting HIV Cases from Africa 24 October 2007: Headache in the HIV+ patient 29 November 2007 : Perinatal HIV Recommendationsin the USA 20 December 2007: Basic HIV 101: Incidence and Background 17 January 2008: Basic HIV 101: Treatment and Meds 28 February 2008: HIV-Related Pulmonary Diseases 27 March 2008: Interesting Recent HIV Cases from Siouxland 22 April 2008: HIV Psychiatry 29 May 2008: HIV Dermatology 26 June 2008: Pneumocystis Pneumonia and HIV 24 July 2008: GI Symptoms and Diseases in the HIV Patient • • • • 28 Aug 2008: Anemia in the HIV Patient (1) 25 Sept 2008: Anemia in the HIV Patient (2) 30 October 2008: Pediatric HIV Update 20 November 2008: HIV and Renal Disease 18 December 2008: Interesting HIV Cases from Africa 29 January 2009: Interesting HIV Cases from SCHC 28 Feb 2009: Basic HIV Treatment Update 29 March 2009: Nervous System Part 1: The Spinal Cord and HIV/AIDS April 2009: Teaching HIV to Primary Care Medical Providers: Experiences from Sioux City and Kenya May 2009: Nervous System Part 2: The Peripheral Nervous System and HIV/AIDS June 2009 Nervous System Part 3: The Brain and HIV/AIDS June 2009: Liver Disease and HIV July 2009: Interesting HIV Cases from SCHC

Methods Utilized- Experiential Knowledge Ø Ø Ø Shadowing- SCHC clinic, Kijabe HIV clinic, Kijabe medical wards, MATEC/Cook Co. Core Center, Omaha HIV clinic Case discussions- UCSF warmline, SC ID physicians, Kijabe HIV Conference, SCHC HIV Conference Hospital Rounding Clinic Drop-ins Patient management. Ø Norman, Geoff et al. Expertise. Ø Ø

Showing Vision- Sites training providers to know

Showing Vision- Sites training providers to know Ø The problem: Most people have no idea what an HIV training site for primary care providers would look like.

Showing Vision- Sites training providers to know Ø The problem: Most people have no idea what an HIV training site for primary care providers would look like. Ø The answer: SCHC, AIC Kijabe Hospital, and now SMEF are all sites where this training is going on with varying degrees of success.

3 Sites Ø 1) Siouxland Community Health Center in Sioux City Ø 2) AIC Kijabe Hospital in Kijabe, Kenya Ø 3) Siouxland Medical Education Foundation in Sioux City

Outline Ø 1) Sowing the Vision: Encouraging a need to know Ø 2) Knowing With Vision: Identifying what to know Ø 3) Growing Vision: Providing a means to know Ø 4) Showing the Vision: Sites training providers to know

Conclusion Ø Gained an awareness of HIV/AIDS issues that affect primary care providers Ø Noted ideas for how to train primary care providers in HIV medicine Ø Saw how HIV/AIDS training must look different in varied settings- i. e. North America vs. Africa

Conclusion