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Our Next Generation in the War on HIV

Wednesday, January 25, 2017

It’s been more than 30 years since the first HIV infection was documented in the United States. And while treatment has improved and the virus is no longer the death sentence it used to be, the number of new infections is holding steady at about 45,000 per year, and the supply of skilled providers is dwindling. The Southeast in particular reflects the grimmest numbers.

Duke University School of Nursing (DUSON) is part of a national effort to educate a new generation of nurses who can assess for early signs of infection and provide patient care aimed at reducing spread of the disease. “There is more mortality [in the Southeast] from HIV than in any other part of the U.S.,” said James (Les) Harmon, DNP’12, RN, ANP-BC, AAHIVS, associate professor and director of the HIV/AIDS specialty program. “It’s important we have students in programs in this part of the country because this is the place with the highest need.”

The HIV/AIDS specialty program, open to students in the Master of Science in Nursing and Doctor of Nursing Practice programs, also offers certification to practicing nurse practitioners. DUSON was one of only five schools to receive the five-year federal Health Resources and Services Administration (HRSA) grant in 2013 and launched the program a year later. To date, DUSON counts 12 graduates and 25 current students. The DUSON program is the only distance-based program in the nation and the only program of its kind located in the Southeast.

According to Henry J. Kaiser Family Foundation, in the U.S., the South accounted for half of all HIV diagnoses in 2014 even though Southern states comprise only 37 percent of the nation’s population. Social determinants of health are a big reason for higher numbers in the Southeast, Harmon said. Poverty, lack of education, poor access to health care, discrimination and stigma contribute to lack of treatment and awareness, which in turn increase the rate at which it spreads.

The HRSA grant aims to address the workforce shortage in HIV care. “We’re seeing the graying of the workforce,” said Harmon, who co-founded the HIV clinic in Henderson, North Carolina, in 1997 and continues to see patients there. “The generation of professionals that started working with HIV in the ’80s, those people are starting to retire.”

Replacing these professionals is difficult because HIV treatment today is so much more effective — and easier. It is no longer viewed as the crisis it once was; there’s no spotlight on the disease spurring providers to action. Also, caring for HIV patients often means dealing with a population that suffers from mental illness, substance abuse, discrimination and stigma. “Our patients have complex health issues. You have to love this work,” Harmon said. “People who want to work in HIV are a unique set of people.”

Kara McGee, MSPH, PA-C, who is deeply involved in the program as an instructor and a preceptor for students agrees wholeheartedly. “I’ve been impressed with the students’ dedication to learning about HIV. They’ve taken on extra classes, additional tuition and time to learn about a disease that practitioners often have little interest in learning about. I am constantly impressed and inspired by the students who choose the HIV concentration,” she said.

Sarah Seaver, MSN’16, APRN, a graduate of the HIV/AIDS specialty program, is one of those people. She did her clinical rotation in Johnson City, Tennessee, where she worked at a Ryan White funded clinic and treated several HIV patients. Having witnessed the stigma of the disease when she worked in public health, Seaver said the main reason she wanted to focus her career on patients with HIV was to advocate for them. Her time spent in the clinic expanded her understanding of the complexity of HIV patients’ health issues and how important it is to have an advocate along with the appropriate medical resources on hand. For instance, depression and mental health issues can complicate and sometimes get in the way of treatment, she said, which can affect outcomes for the patient and contribute to a higher risk of infection. Having a wider perspective can help provide the best care for the patient.

“Being there I get to see up-to-date, high-quality, evidence-based primary care and HIV care being delivered,” she said. “It’s a really good example of a setting that was a multidisciplinary team-based approach.”

Being able to talk comfortably with patients about sexual and high-risk behaviors was one of the most valuable skills Seaver said she learned from the program. She plans to use her education to bring HIV care into a primary care clinic in Boone, North Carolina, where she will be working. “What I’m hoping is that I can be a resource to my colleagues here and spread the word so patients and providers know I’m here and can refer folks to me.”

Bringing HIV care into the primary care setting is one of the overall goals of the program, Harmon said. Patients are living longer, healthier lives, so primary care providers are likely to treat HIV patients for other issues. Because of this, in addition to the specialty, Harmon said the School has threaded HIV education throughout its general curriculum, focusing on pharmacological, social and epidemiological dimensions of the virus. “Every student who graduates from the Duke nurse practitioner program has some basic knowledge of HIV,” Harmon said. “That’s an important part of what we’re trying to do.”

The program aims to teach every student how to identify patients with an acute HIV infection. A flu-like illness with fever and a rash, it is often misdiagnosed unless you are specifically looking for it, Harmon said. About 13 percent of the HIV infected population doesn’t know they have the disease. Even though it’s been recommended since 2006 as a routine screening, many primary care providers don’t do it unless the patient is identified as at-risk, and many patients hide their risk factors, which makes it difficult to prescribe treatment and keep them from infecting others.

“There’s a big push to try to get people tested and get them in care and retain care,” Harmon said. “If you can get someone on medication and suppress the virus completely, then their chance of transmitting HIV to someone else is very, very low.”

Complex Patients

Treating HIV patients and stopping the virus’ spread used to be a medical crisis. The virus received national attention, and public health announcements were aimed at getting the word out about prevention. Increased awareness and understanding and improvements in therapies have resulted in great success; newly infected people in treatment today lead virtually normal lives, and many patients who had HIV for years are seeing dramatic turnarounds after therapeutic intervention. Needle exchange programs have cut down on the incidence of spread through intravenous drug use. Men having sex with men remain the group with the highest rate of infection, but it can be hard for the younger generation to see what the big deal is.

“There’s a lot of anecdotal evidence that young men these days never saw the bad side of HIV,” Harmon said. “They have friends who have HIV and take one pill once a day, and they’re fine. They go on with their lives.”

Many worry that false confidence about the disease creates a cavalier attitude toward HIV that may lead to riskier sexual behavior and the disease spreading. But other dangerous behavior, like drug abuse that leads to promiscuity, can also be the result of things like depression and mental distress, said Robert Dodge, MSN’96, PhD, RN, ANP, AACRN, who has worked with HIV patients for 25 years and was a co-founder of the clinic in Henderson with Harmon and Tony Adinolfi, MSN’93. Now a clinical associate professor at University of North Carolina at Chapel Hill, he is a preceptor for the DUSON HIV/AIDS specialty program and supervises students at the HIV/STI Clinic at Wake County Human Services, where he is the clinical director. Dodge said DUSON does an excellent job of teaching its students to look at the whole patient.

“A good 60 percent [of patients], if not more, have some mental-health related problems that cause them to run down the path of risky behavior,” he said. “These patients are complex. This is not an average healthy person. They have multiple issues, and it can be overwhelming.”

The clinic in Wake County is a Ryan White “BC” clinic, which means in addition to HIV care, it offers primary care free of charge. This has been a major benefit to patients, Dodge said, as many of them have no insurance or are underinsured. The NP students who work at the clinic are able to see all sorts of patient health issues in a primary care setting and how those issues interact with HIV.

“I try to make sure our students realize HIV may be the easy part, but how do you manage it on a long-term basis,” Dodge said. People rarely die from HIV, there are fewer side effects, but the patient may have a host of other issues that need addressing, like diabetes and hypertension, he said. “I’m a therapist, I’m a nutritionist, I’m an adherence counselor. Now I’m back to a substance abuse counselor. You really become a multi-specialist.”

But HIV treatment can be a double-edged sword. Pre-exposure prophylaxis (PrEP) drugs work but only if taken every day, Dodge said. The anti-retroviral drug prevents the person taking it from acquiring the virus. But if not taken consistently, it becomes much less effective. Young people or those with mental or substance abuse problems may not adhere to their protocols, which makes them susceptible to catching and spreading HIV.

Maurice Brownlee, MSN’16, DBA, MBA, RN, CPHRM, FASHRM, CHC, a graduate of the HIV/ AIDS specialty program who has worked with patients in Chicago and Atlanta, says the patients he sees in Atlanta are mostly young African-American men between the ages of 19 and 27 who fall in and out of care. He says while lack of insurance and education play a large roll, stigma may even be the more difficult challenge to managing HIV-infected patients. Some hot spots of new HIV infections in Atlanta are in higher income areas, he said, which makes him think it’s not all about being poor and uneducated.

“You get HIV because of behaviors in general that we don’t want to talk about: through sex and drugs,” said Brownlee. “Churches don’t discuss it and families don’t discuss it, and there has been very little research on young African-American HIV patients,” he said. “So it’s hard to know what exactly is happening.”

Brownlee does know that young people are more likely to have anonymous sexual encounters, especially with the availability of phone “sex apps.” “Sex is easy to get now,” he said, and with this type of sex, there’s no incentive to disclose your health status. “That could be the last time you see that person.”

An enthusiastic proponent of the specialty program at DUSON, Brownlee noted he’s been offered a job at every clinical rotation he’s had. “Employers are like ‘Oh my, I can cut out that learning curve and put you right to work,’ and you can,” he said. “You can practice proficiently. [The program] is much-needed, so I’m proud to be part of this.”

Pride is also a feeling that McGee describes about being a part of the program. “Honestly, I feel very proud and very fortunate, proud that I played a role in educating the graduates and that they are having a direct impact on the workforce caring for people living with HIV,” she said. “And I feel very fortunate that the Duke School of Nursing trusts me with this responsibility and sets an example of the importance of interprofessional collaboration to educate future health care providers.”

The HIV/AIDS specialty program is in its fourth year of the five-year grant cycle. Harmon is hoping the School will continue the program by reinforcing HIV content throughout the curriculum. “There’s every reason to think that in your career, you’ll be treating people with HIV in a [primary care] setting, so you need to know about it,” he said.