Developing the HIV Workforce: The MATEC Clinician Scholars Program

Feature

Developing the HIV Workforce: The MATEC Clinician Scholars Program Malinda Boehler, MSW, LCSW Barbara Schechtman, MPH Ricardo Rivero, MD, MPH Beth-Anne Jacob, PhD, LCSW Renslow Sherer, MD Cornelia Wagner, MBA, MEd Salma A. Alabduljabbar, BS Nathan L. Linsk, PhD, ACSW* Engaging new clinical providers in the HIV workforce is a critical need due to rapidly evolving treatment paradigms, aging out of existing providers, and special population needs. The 1-year competency-based Clinician Scholar Program for minority-serving providers with limited HIV care experience was individually tailored for each provider (n 5 74), mostly nurse practitioners, physicians, and clinical pharmacists. Baseline and endpoint self-assessments of clinical knowledge and skills showed significant improvements in all 11 targeted competencies, particularly in managing antiretroviral medications, screening and testing methods, incorporating prevention into HIV care, understanding risk reduction methods, and describing current care standards. Faculty mentor assessments also showed significant improvement in most competencies. Additional benefits included ongoing access to mentorship and training, plus sustained engagement in local and statewide HIV care networks. Our intensive mentoring program model is replicable in other AIDS Education and Training Centers and in other structured training programs. (Journal of the Association of Nurses in AIDS Care, -, 1-15) Copyright Ó 2015 Association of Nurses in AIDS Care Key words: AIDS Education and Training Centers, clinical training, HIV, provider education, workforce development

A

lmost 1.2 million people in the United States have been diagnosed with HIV, and almost 650,000 lives have been lost (Centers for Disease Control and Prevention, 2013). Antiretroviral therapy (ART) increasingly allows people with HIV to live longer and healthier lives. One study estimated that patients Malinda Boehler, MSW, LCSW, is the Site Director, Midwest AIDS Training 1 Education Center (MATEC) State Site in Indiana, Eskenazi Health, Indianapolis, Indiana, USA. Barbara Schechtman, MPH, is an independent consultant, Evanston, Illinois, USA. Ricardo Rivero, MD, MPH, is the Executive Director, MATEC, Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, USA. Beth-Anne Jacob, PhD, LCSW, is Director of Research and Evaluation, MidAmerica Center for Public Health Practice, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA. Renslow Sherer, MD, is a Professor of Medicine, Department of Infectious Diseases, University of Chicago, Chicago, Illinois, USA. Cornelia M. J. Wagner, MBA, MEd, is the Evaluation Coordinator, MATEC, Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, USA. Salma A. Alabduljabbar, BS, is a Research Assistant, MATEC, and a Masters in Public Health Student, DePaul University, Chicago, Illinois, USA. Nathan L. Linsk, PhD, ACSW, is a Professor of Social Work, Family Medicine, and an Emeritus Professor, Jane Addams College of Social Work, MATEC, University of Illinois at Chicago, Chicago, Illinois, USA. (*Correspondence to: [email protected]).

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. -, No. -, -/- 2015, 1-15 http://dx.doi.org/10.1016/j.jana.2015.06.006 Copyright Ó 2015 Association of Nurses in AIDS Care

2 JANAC Vol. -, No. -, -/- 2015

newly diagnosed at age 20 years in North America in 2007 could expect to live 51.4 more years, approaching a natural life expectancy (Samji et al., 2013), but only when people living with HIV (PLWH) access and adhere to HIV care. The number of minority and minority-serving providers in disproportionally affected minority communities remains inadequate. While minority groups of African Americans, Hispanic Americans, and Native Americans make up more than 25% of the U.S. population, they make up only 6% of physicians and 9% of nurses, exacerbating the disparities in health status in the United States (Sullivan Commission, 2004). The National HIV/AIDS Strategy (The White House Office of National AIDS Policy, 2010) calls for increased training of health care providers to meet the needs of PLWH. Projections of health care provider shortages indicate that 18% of the health care workforce is currently older than 55 years of age, including almost 25% of physicians and almost 20% of registered nurses (U.S. Department of Health and Human Services, Health Resources and Services Administration [HRSA], National Center for Health Workforce Analysis, 2013). A 2008 survey of HIV providers indicated that a third of respondents planned to retire within 10 years–by 2018 (American Academy of HIV Medicine [AAHIVM] & HIV Medicine Association [HIVMA], 2009), clearly suggesting the need to train more providers to fill the gap as this current generation of HIV clinicians leaves the field. A study of providers in the federally funded Ryan White HIV Program indicated that 70% were having a difficult time recruiting HIV care providers to fill open positions (AAHIVM & HIVMA, 2009). This gap is particularly concerning for HIV providers from minority communities, which are those most affected by the epidemic. Black and Hispanic patients are more likely to rate care as excellent or very good when providers share their racial backgrounds (Saha, Komaromy, Koepsell, & Bindman, 1999). A number of studies have examined issues of racial concordance in clinical care and training programs. Enriquez and colleagues (2008) compared health outcomes of low-income Hispanic/Latino adults living with HIV 1 year before and after implementation of a bilingual/bicultural care team at an academic HIV specialty clinic. During the year after the new care team was implemented, there was a

significant increase in the number of clinic visits per patient, significant increase in the percentage of patients with suppressed viral loads, and significant increase in CD41 T cell counts among those virally suppressed. Sohler, Fitzpatrick, Lindsay, Anastos, and Cunningham (2007) polled 380 HIV-infected patients, both Hispanic/Latino patients and African American, who reported significantly higher mistrust with the HIV-related health care system than White patients; however, patients with race-/ethnicityconcordant providers rated significantly lower mistrust than those with race-/ethnicity-discordant providers. A multicenter study that examined the role of cultural distance between HIV-infected patients and providers in perceived quality of care found that patients who rated lower perceived cultural similarity with their providers rated significantly lower quality of care and lower trust in their providers. Cultural concordance was assessed in terms of speech and language, reasoning, communication style, and values, which, based on the findings of the study, indicated the importance of positive patient-provider interactions and cultural competency in provision of HIV care (Saha et al., 2011). Saha and colleagues (2013) also investigated providers’ self-rated cultural competency on how that self-rating related to their patients’ outcomes, and found that patients of providers with ratings from middle to highest on cultural competency were significantly more likely to be on ART, score higher on self-efficacy in managing medications, and adhere to ART (Saha et al., 2013). There were also significantly fewer racial disparities in receipt of ART, self-efficacy, and viral suppression among patients of providers with middle to highest ratings on cultural competency compared with those of providers with low ratings (Saha et al., 2013). Given these realities, the need for culturally competent clinicians, particularly from the communities most affected by HIV, is crucial. Another important consideration for increasing the number of qualified HIV clinicians is the advent of the Patient Protection and Affordable Care Act, giving new access to health insurance to millions of Americans and emphasizing primary care settings as the locus of care for most chronic conditions, including HIV. Many community health centers (CHCs), which will serve more patients as more

Boehler et al. / The MATEC Clinician Scholars Program

people are insured, have very few or no current patients with HIV. In Illinois, for instance, 14 of the 42 federally funded CHCs have reported no patients with an HIV diagnosis, and another 12 reported fewer than 50 patients (HRSA, 2009). Thirteen of these clinics were in the Chicago metropolitan area, which has almost 30,000 PLWH (Illinois Department of Public Health, 2013). The Illinois example suggests that CHCs will require considerably more preparation for HIV-infected patients who will be coming to them for care in the near future. While traditional health provider pre- and inservice education, such as workshops and grand rounds, has incorporated HIV-related content since the epidemic began, a focused effort to establish regional education and training programs started in 1987 when the HRSA established the AIDS Education and Training Centers (AETCs). This national network of regional training centers supports health care providers who care for PLWH (HRSA, 2014). In response to the continuing need for new HIV care providers, the Midwest AIDS Training 1 Education Center (MATEC), a regional HRSA-supported AETC, developed the MATEC Clinician Scholars Program (CSP), a year-long mentoring and training program designed to expand the number of clinicians competent to care for people with HIV disease. In this article, we review related background and previous evaluations of related education and training programs, followed by a description of the CSP and evaluation findings to date.

3

HIV care settings’’ and to facilitate ‘‘practice change with a focus on inter-professional team development’’ (National Alliance for HIV Education and Workforce Development, 2014, p. 3). AETC longterm clinical training approaches vary between the regional centers. Other organizations beyond the AETCs support HIV care providers, including efforts by the International Association of Providers of AIDS Care (2014), HealthHIV (2015), HIVMA (2012), and AAHIVM (2010). Each group takes a different approach to providing training, with approaches including Webbased developmental continuing medical education courses (HealthHIV, 2015), online clinical guidance documents (International Association of Providers of AIDS Care, 2014), HIV credentialing with resource documents for study (AAHIVM, 2010), and Minority Clinical Fellowships with salary support for two African American and Latino clinicians per year (HIVMA, 2012). While all of these groups have provided potentially useful support for developing new HIV-competent clinical providers, to date, only the AETCs have offered regionally based year-long training and mentoring to working clinicians in their own communities. International programs for training HIV clinicians have used ongoing clinical mentoring such as the Clinton Foundation (2007) and the International Training Center for Health (2011), which pair newer and more experienced clinicians for learning and ongoing clinical support. Training Program Methods

Background and Review of Previous Programs AETC training methods include seminars and workshops to provide expanded clinical knowledge of HIV, skill-building programs targeting specific practice skills, observation and participation in clinical settings to learn HIV diagnosis and treatment skills from skilled providers, and clinical consultation and technical assistance (HRSA, 2009). The National Alliance for HIV Education and Workforce Development has recommended ongoing development of the HIV workforce by the AETCs to provide ‘‘longitudinal capacity-building assistance tailored to individual

Several studies have suggested that a multimodal approach that includes a series of learning opportunities and that allows for consultation and support may lead to more satisfaction with training, increased knowledge, and greater intention to change. Models that used a multimodal approach, including interactive learning delivered in a longitudinal manner, produced more positive outcomes than models that used single sessions. Objectively assessing learners’ needs and providing opportunities for follow-up with facilitators also improved the effectiveness of continuing medical education programs. Cook, Friedman, Lord, and Bradley-Springer (2009) evaluated outcomes of provider training programs over an

4 JANAC Vol. -, No. -, -/- 2015

18-month period and found that higher levels of selfreported practice behaviors were significantly associated with higher number of training events attended (p 5 .046) and higher percentages of interactive instructional events attended (p 5 .025) by each participant. Trainees who attended individual consultations reported higher levels of recommended practice behaviors (p , .001), and those who attended clinical preceptorships reported more rapid improvements in practice behaviors (p 5 .002) compared to those who did not attend clinical preceptorships (Cook et al., 2009). Longitudinal Training Some evidence shows that longitudinal trainings coupled with mentoring opportunities have positive effects. Mill and colleagues (2014) implemented and evaluated a four-site mentorship program that brought together nurses experienced in care for PLWH and nurses who wanted to learn more about HIV nursing care. Mentorship education was perceived as effective in increasing knowledge about HIVand reducing stigma and discrimination in nurses providing HIV care. A Botswana chart review (N 5 374) evaluation (Workneh et al., 2013) of an outreach mentoring program to scale up expanded quality pediatric HIV care and treatment given by medical officers, nurse clinicians, and nurses showed improved documentation of pill count, recording of viral load results, correct laboratory monitoring, and correct ART dosing. In a regional on-site longitudinal training program tailored for multidisciplinary HIV care professionals at six clinics, the majority of participants reported increases in their HIVrelated knowledge and skills; however, reported lack of enabling factors in their clinical environments, such as encouragement from colleagues, opportunities to apply what they learned from training, and support for making changes, may have affected their abilities to apply new knowledge and skills (Culyba, McGee, & Weyer, 2011). Finally, Rosen and colleagues (2005) evaluated a year-long high-intensity longitudinal training model developed in collaboration with an AETC to improve HIV care. The program included half didacticcontent presentations and half direct patient encounters observing experienced clinicians providing

patient care. Compared to the previous 2 years, when only traditional off-site trainings were offered, the number of participants receiving clinical consultations more than doubled, and participants’ responses to standard process evaluation questionnaires about the quality of the training program were positive. Impact of Training Provider education and training has been shown to improve clinicians’ HIV knowledge, skills, and practices (Linsk et al., 2002; Mulligan, Seirawan, Galligan, & Lemme, 2006), while interactive and mixed-method education programming and mentoring over time (Workneh et al., 2013) have produced the most positive outcomes. Horberg and colleagues (2012) found that improved adherence to ART was associated with greater years of provider experience, whereas viral suppression among ART-na€ıve patients was positively associated with patient panel size and negatively associated with the provider’s years of experience. Linsk, Carr, and Schechtman (1997) evaluated the outcomes of AETC programs an average of 9 months after training; 40% of the participants reported an increased number of HIV-infected patients served in their individual practices and 75% reported practice changes, especially changes in risk assessment, counseling, and overall increased confidence in providing HIV care. Using openended Web-based follow-up surveys, Bashook and colleagues (2010) found that 54% of participants who attended skill-building workshops reported examples of implementing changes in their individual clinical practices and in the care delivery systems, which they attributed to participation in training involving attitude, knowledge, and behavior changes in the providers’ individual practices. An interview study conducted 8 months post training with participants of nine diverse multistate HIV training programs reported positive effects in providers’ perspectives on HIV, their practice behaviors, and how health care systems delivered HIV care (Huba et al., 2000). Eighty-two percent of the participants provided examples of changes in patient care, such as the amount, frequency, and quality of educating patient/family, or counseling and HIV testing (Lalonde et al., 2002).

Boehler et al. / The MATEC Clinician Scholars Program

MATEC Clinician Scholar Program MATEC includes seven Midwestern states (Illinois, Minnesota, Wisconsin, Michigan, Indiana, Iowa, and Missouri). While MATEC provides central coordination of goals, activities, and data collection and reporting, each State Site relies on its knowledge of local resources and needs to develop contextually appropriate programs to engage new clinicians in HIV care as well as continuing education, clinicbased learning opportunities, and clinical consultation for existing providers. In the early 1990s, MATEC began to establish a regional clinical mentoring program. The program was built on the premise that HIV care was dynamic and required a unique set of care skills to meet the needs of underserved communities impacted by the epidemic. In 2009, a regional workgroup developed standardized program objectives, structures, and activities that were closely tied to the needs of an emerging workforce. As a result, the MATEC CSP was created. Expected Core Capabilities The CSP was designed to increase the capacity of clinicians to diagnose, treat, manage, and prevent HIV infection. Funded by the Health and Human Services Department Minority AIDS Initiative, the 1-year program was specifically designed for minority, or predominately minority-serving, front-line clinical care providers (physicians, nurse practitioners, advanced practice nurses, physician assistants, registered nurses, oral health providers, and pharmacists). The program concentrated on the following core capabilities established by MATEC’s clinical and program leadership and 33 related learning objectives: 1. Use local, national, and international epidemiology data to identify emerging trends in the epidemic and potential impact on practice and HIV testing. 2. Use current Department of Health and Human Services treatment guidelines, including those related to special populations, to manage HIV infection.

5

3. Incorporate current standards of care, including those related to special populations, into management of HIV infection. 4. Use results of CD41 T cell count, HIV viral load, and HIV resistance testing in combination with ART history to choose optimum treatment regimens. 5. Manage treatment failure. 6. Address factors that may inhibit a patient’s adherence to a prescribed treatment regimen. 7. Institute appropriate opportunistic infections prophylaxis, and diagnose and manage or refer common opportunistic infections. 8. Diagnose and manage common HIV-related clinical syndromes and manage common comorbid conditions related and unrelated to HIV disease. 9. Recognize and manage common ART side effects and drug interactions with those medications. 10. Provide appropriate and professional screening and referral or risk/harm reduction counseling related to sexual behaviors, drug use, and mental health. 11. Provide care that incorporates patient race, ethnicity, gender, age, sexual orientation, and the myriad psychosocial issues impacting patient’s lives. The aim was to ensure that all participants who completed the CSP were proficient in areas necessary to provide an intermediate level of HIV care. Although the program was not specifically designed to develop clinicians as MATEC faculty, participants were fostered as faculty if they expressed an interest and completed additional training hours beyond those required to complete the CSP. CSP guidelines for teaching these core capabilities included both clinical mentorship and a structured series of in-person and distance-learning activities for all clinicians. The CSP included clinical preceptors and training faculty, as well as the roles of CSP Monitors and Mentors. Mentors were experienced local HIV clinicians responsible for directly overseeing clinical training of the participants (and/or for linking them with one or more experienced HIV clinicians). A Mentor reviewed and approved each Scholar’s

6 JANAC Vol. -, No. -, -/- 2015

individual learning plan, and completed interim and final evaluations of the Scholar. In most cases, the Mentor was the Medical Director for the State Site. Faculty who provided clinical leadership for the State Sites provided mentorship as part of their ongoing activities or were compensated for their efforts as contractors. Monitors at the State Sites were responsible for shepherding Clinician Scholars through their courses of study. Monitors made sure that participants met with Mentors and completed course requirements. They also facilitated learning opportunities and engagement with Mentors. Conceptual Approach The CSP used five major education elements: (a) Intensive mentoring–ongoing guidance, advising, and consultation from a local expert HIV clinician over the course of 1 year; (b) Individualized approach–each Clinician Scholar identified his/her own learning needs and program expectations and worked with a Monitor and a Mentor to achieve these objectives through a yearlong structured curriculum, an annual day-long skills-building workshop at the start of the program, and periodic self-evaluations; (c) Personal connections and relationships–participants engaged with each other, MATEC staff, and other HIV experts on a regular basis and continued connections after program completion, providing important ongoing support for Clinician Scholar HIV clinical competency; (d) Longitudinal approach–participants committed themselves to a 1-year program of professional development as part of the CSP and opportunities for clinical training after completion of the program were encouraged and supported; and (e) Localized context with regional support–participants learned within their own work settings, developing learning objectives and activities with a local Mentor who understood the participant’s practice context, connecting with other clinicians in the region who worked in similar settings as well as local and regional networks of multidisciplinary HIV caregivers and support staff.

intensive and individualized experiences. Criteria for the CSP included that applicants (a) provided direct clinical care to a patient population significantly comprised of minority populations, or that the applicants themselves were African American, American Indian, foreign born (e.g., African), and/or Hispanic; (b) planned to continue to practice within the region served by MATEC; and (c) demonstrated an elementary knowledge of basic HIV concepts (local epidemiology, natural history of the disease, pathogenesis, and comorbid conditions) to the satisfaction of their State Site coordinator or Monitors. Additional criteria included providing care in a setting reaching populations most in need of care (e.g., Ryan White-funded clinics, corrections settings); and serving other medically underserved (e.g., low-income, Medicaid-eligible) communities or patients receiving assistance from the AIDS Drug Assistance Program. Core Program Components The CSP consisted of three components, as shown in Figure 1. Clinician Scholars chose from a variety of learning activities including clinical preceptorship hours, where Clinician Scholars observed and participated in HIV care under the supervision of Mentors. Clinician Scholars began participation in the CSP each year by attending an annual HIV Update dinner

Entry Criteria The CSP intentionally kept the number of participants enrolled sufficiently limited to allow for

Figure 1. Core programmatic components of the Clinician Scholars Program.

Boehler et al. / The MATEC Clinician Scholars Program

program in Chicago, which recognized programcompleting Clinician Scholars and welcomed incoming participants. A 1-day multidisciplinary orientation session included didactic presentations and case discussions about HIV prevention, care, and support. In collaboration with his/her Mentor, each Scholar developed a plan to meet personal learning needs within the minimum program requirements. The menu of training experiences included intensive 1-day seminars, online programming, teleconferences, one-on-one sessions with Mentors, independent study modules, observed structured clinical examinations, and/or clinical consultations. Over the year, participants were closely monitored and mentored as they worked to fulfill each component of the program. Clinician Scholars who completed all required program components were awarded Certificates of Participation. Program Evaluation Methods From the time of enrollment, Clinician Scholars understood that participation in all evaluation activities was an important element of the program. The program application included demographic and practice information. Clinician Scholars completed entrance and exit interviews about their goals and achievements (not reported here). The evaluation process evolved as the program was refined over time. The program was initiated in 2010-2011; however, the evaluation components reported here were not fully implemented until Year 3, 2012-2013. Since then, participants have completed baseline and endpoint self-assessments of their own capabilities. The self-assessment surveys consisted of 33 specific learning objectives that constituted the 11 core capabilities shown above. Participants rated each of their own capabilities using Table 1.

7

a 4-point scale, with 4 5 the highest level of competency. The instrument was developed by MATEC staff as a standardized tool to help State Sites identify the training needs of Clinician Scholars and assess participant learning progress over the course of the program. Mentors assessed participants on the same scale (ranging from minimally capable to fully capable) at the midpoint and endpoint of the program, rating the Clinician Scholars on the same 33 learning objectives. The self-assessment and Mentor assessment instruments were tested for reliability by calculating Cronbach’s alpha. The internal consistency of both instruments exceeded 0.90, indicating that the instruments were reliable. MATEC clinical trainers also reviewed the instruments to ensure content validity. All participants signed informed consents for participation and the University of Illinois Institutional Review Board initially approved all procedures in 2002 with annual continuing reviews. Monitors and Mentors prepared ongoing transcripts of all program activities. Participants also completed standard evaluations for each individual learning activity, including immediate self-report postprogram evaluations and Web-based follow-up surveys (AETC National Evaluation Center, 2015) to measure the impact of training on clinical practice (data not included here).

Results Participants Over a period of 5 years, the number of Clinician Scholars admitted to the program per year ranged from 9 to 18, yielding a total enrollment of 74. During the first 4 years, 56 participants were enrolled, of whom 51 (91%) completed the program; 80% were

Activities Clinician Scholars (N 5 25) Engaged in During Training in Hours

Type of Activity

Training Level

In-person lecture or webinar Workshop or evening seminar Clinical preceptorship Clinical consultation Technical assistance Mean total hours of participation

1. Didactic training 2. Skill-building workshop 3. Participation in clinic with a preceptor 4. Case-based discussion with clinical expert 5. Consultation on development of clinical program(s)

Mean Hours per Activity Per Clinician Scholar 7.6 31.7 19.8 1.1 1.2 61.4

8 JANAC Vol. -, No. -, -/- 2015

female. Participant ages ranged from 25-63 years, with the largest portion in their 30s. Almost one third of participants identified as members of a racial minority, with 9.5% of participants identifying as Asian, 18.9% identifying as Black or African American, and 2.7% identifying themselves as mixed-race heritage. Participant years of HIV experience ranged from less than 1 year (n 5 4) to more than 10 years (n 5 6); overall, 80% had 2 or fewer years of HIV clinical experience (mean 5 3.89 years). The majority of participants (54%) were advanced practice nurses, one quarter were physicians, and 16% were clinical pharmacists. More than one third (35%) worked in community health centers and one fifth worked in HIV-identified clinics; 10% indicated they worked in academic health centers, and fewer worked in hospital-based clinics (4%), infectious disease clinics (8.2%), or private practices (5.4%). Only 7% indicated they were from rural areas; the rest were from urban or suburban areas. In terms of clinical HIV experience, we examined information from the 25 Clinician Scholars who participated in years 3 and 4 of the program. Before the program, 40% of participants provided direct care to an estimated 20 to 49 HIV-infected patients per month, 20% provided care to an estimated 1 to 9 patients, 20% served more than 50 patients, 12% cared for 10 to 19 patients, and 8% indicated that they did not provide direct care to PLWH. Participant Learning Activities Table 1 displays the learning activities completed by participants as reported on individual transcripts maintained at each State Site. Results from years 3 and 4 only are shown here because these years had the most complete evaluation data (in prior years, the evaluation components were still in development and testing phases). The total combined number of hours spent participating in each learning activity was calculated by adding hours recorded on the individual transcripts. Then, for each learning activity, the total number of hours was divided by the number of participants in attendance (n 5 25) to determine the mean number of hours per activity per Scholar. Clinician Scholars completed an average of more than 60 training hours, well beyond the minimum hours required. The majority of time (nearly

32 hours) was spent in skill-building workshops. Similarly, Clinician Scholars spent an average of almost 20 hours in clinic-based observation or activities, again exceeding the minimum 12-hour requirement.

Participant Self-Assessments Table 2 shows results from participants who completed both baseline and endpoint selfassessments of the 11 capabilities for years 3 and 4 of the program. For each participant, scores for the learning objectives for each capability were averaged; separate means were obtained for baseline and endpoint data. An increase between baseline and endpoint indicated a higher self-assessment of competency at the end of the program. For the 20 evaluable data sets (five participants did not complete an assessment at one of the time points), all 11 core capabilities were rated with a statistically significant (p , .05) increase in ratings. The greatest amount of change occurred for the following items, with increases of 30%-50% for each (numbers refer to the competency numbers): (a) Provide appropriate and professional screening and referral or risk/harm reduction counseling related to sexual behaviors, drug use, and mental health (10); (b) Recognize and manage common clinical syndromes related to HIV disease; manage common comorbid conditions related and unrelated to HIV disease (8); and (c) Diagnose and manage common ART side effects and drug interactions with those medications (9). The competencies with the least improvement had higher baseline scores, and hence had less room for improvement; these items included: (a) Use local, national, and international epidemiology data to identify emerging trends in the epidemic and potential impact on practice and HIV testing (2); (b) Use results of CD41 T cell count, HIV viral load, and HIV resistance testing in combination with ART history to choose optimum treatment regimens (4); and (c) Address factors that may inhibit a patient’s adherence to prescribed ART (6). However, statistically significant changes in all areas indicated that participants felt they had improved substantially on all 11 core capabilities from beginning to completion of the program.

Boehler et al. / The MATEC Clinician Scholars Program Table 2.

9

Baseline and Endpoint Self-Assessments Mean Mean Baseline Endpoint Mean (N 5 20) (N 5 20) Difference p-Value

Capability 1

Use local, national, and international epidemiology data to identify emerging trends in the epidemic and potential impact on practice and HIV testing. 2 Use current DHHS treatment guidelines, including those related to special populations, to manage HIV infection. 3 Incorporate current standards of care, including those related to special populations, into management of HIV infection. 4 Use results of CD41 T cell count, HIV viral load, and HIV resistance testing in combination with ART history to choose optimum treatment regimens. 5 Manage treatment failure. 6 Address factors that may inhibit a patient’s adherence to prescribed ART. 7 Institute appropriate OI prophylaxis, and diagnose and manage or refer common OIs. 8 Recognize and manage common clinical syndromes related to HIV disease. Manage common comorbid conditions related and unrelated to HIV disease. 9 Diagnose and manage common ART side effects and drug interactions with those medications. 10 Provide appropriate and professional screening and referral or risk/harm reduction counseling related to sexual behaviors, drug use, and mental health. 11 Provide care that incorporates patient’s race, ethnicity, gender, age, sexual orientation, and the myriad psychosocial issues impacting patients’ lives.

2.68

3.55

.87

.0001

2.48

3.53

1.05

.0001

2.42

3.63

1.22

.0001

2.88

3.77

.88

.0001

2.23 2.91 2.18

3.40 3.85 3.37

1.17 .93 1.18

.0001 .0001 .0001

2.17

3.43

1.27

.0001

1.90

3.15

1.25

.0001

2.40

3.70

1.30

.0001

2.63

3.72

1.08

.0001

ART 5 antiretroviral therapy; OI 5 opportunistic infection; DHHS 5 Department of Health and Human Services. Note. p , .05 indicates a significant result.

Mentor Assessments Table 3 shows the Mentor assessments of the participants from years 3 and 4 for the same 11 capabilities. Mean scores per participant per capability were calculated and then summarized to find the aggregate mean for each capability at the midpoint and endpoint of the program. An increase in the mean rating from the 6-month to 12-month assessment indicated a higher level of competency at the end of the program. Data from 22 participants were available for 8 of the 11 core capabilities. Data were missing for three capabilities at the 6-month assessment for a few participants; therefore, these capabilities show data for 22 or fewer participants. All Mentor capability assessments showed improvement in mean scores with one item remaining the same. Statistically significant (p , .05) increases were found in all capabilities, with three exceptions. These were (a) Use results of CD41 T cell count, HIV viral load, and HIV resistance testing in combination with ART history to choose optimum treatment regimens (4); (b) Address factors

that may inhibit a patient’s adherence to prescribed ART (6); and (c) Provide care that incorporates patient’s race, ethnicity, gender, age, sexual orientation, and the myriad psychosocial issues impacting patients’ lives (11). For item 4 related to CD41 T cell count, viral load, and resistance testing, there was no change. The fact that the mean was 3.67 (out of a maximum of 4) at both time points indicated that Mentors thought the Clinician Scholars had mastered this capability by the 6-month point. The greatest increase occurred in capability for item 8: Recognize and manage common clinical syndromes related to HIV disease, and manage common comorbid conditions related and unrelated to HIV disease. Other capabilities with large increases included item 5: Manage treatment failure, and item 7: Institute appropriate OI prophylaxis, and diagnose and manage or refer common OIs. We found a strong concordance between the 12-month ratings of the Mentors and those of the participant self-reported assessments, with no differences greater than 0.5 on any item. To strengthen the findings, we conducted an analysis to

10 JANAC Vol. -, No. -, -/- 2015 Table 3.

1

2 3 4

5 6 7 8

9 10

11

Mean Comparisons of Mentor Assessment Data Capability

N

6-Month Mean

12-Month Mean

Mean Difference

p-Value

Use local, national, and international epidemiology data to identify emerging trends in the epidemic and potential impact on practice and HIV testing. Use current DHHS treatment guidelines, including those related to special populations, to manage HIV infection. Incorporate current standards of care, including those related to special populations, into management of HIV infection. Use results of CD41 T cell count, HIV viral load, and HIV resistance testing in combination with ART history to choose optimum treatment regimens. Manage treatment failure. Address factors that may inhibit a patient’s adherence to prescribed ART. Institute appropriate OI prophylaxis, and diagnose and manage or refer common OIs. Recognize and manage common clinical syndromes related to HIV disease. Manage common co-morbid conditions related and unrelated to HIV disease. Diagnose and manage common ART side effects and drug interactions with those medications. Provide appropriate and professional screening and referral or risk/harm reduction counseling related to sexual behaviors, drug use, and mental health. Provide care that incorporates patient’s race, ethnicity, gender, age, sexual orientation, and the myriad psychosocial issues impacting patients’ lives.

22

3.41

3.81

.40

.009

22

3.26

3.65

.39

.001

22

3.35

3.74

.39

.002

22

3.67

3.67

22 22 22

2.92 3.71 3.08

3.61 3.89 3.55

.68 .18 .47

.0001 .062 .001

20

2.64

3.42

.78

.002

19

3.39

3.65

.26

.024

20

3.25

3.63

.38

.003

22

3.66

3.80

.13

0.158

0

N/A

ART 5 antiretroviral therapy; OI 5 opportunistic infection; DHHS 5 Department of Health and Human Services. Note. p , .05 indicates a significant result.

strengthen the validity of self-assessment data by conducting a correlation between the mean of the self-assessment data and the mean of Mentor assessment data as a more objective clinical judgment of each capability. D’Eon and Trinder (2014) demonstrated that grouped self-assessment data can be valid measures of overall group performance when used as outcome data in program evaluation studies. Using correlation analysis, we compared the group means obtained from individual self-assessments and the means of Mentor assessments across the 11 capabilities at the end of the program (N 5 20). We found a strong, statistically significant correlation (r 5 .62, p , .05), which suggested that grouped self-assessments may be valid indications of group outcomes for the CSP.

Discussion and Conclusions Our findings reveal that the individualized 1-year mentored MATEC CSP engaged minority-serving clinicians in our seven-state Midwest region and that self and mentor assessments showed improved abilities of these clinicians to diagnose, treat, manage, and prevent HIV disease, attributed to program participation. The CSP placed an explicit focus on a training curriculum and pedagogy that concentrated on 11 core capabilities; modest to substantial improvement was reported by Clinician Scholars and their Mentors for each of the core skills. This finding was both intriguing, given that each clinician crafted her/his own course of training in collaboration with a Mentor based on personal levels of experience and learning needs, and reassuring, in that a heterogeneous learner-centered

Boehler et al. / The MATEC Clinician Scholars Program

approach led to improved competency in all the skills measured over the course of the program. CSP is a multimodal and multidisciplinary approach within the existing AETC training infrastructure for emerging clinicians working in frontline HIV care settings. Examples of ancillary benefits included linkages to state- and regionwide clinical experts, access to local and regional HIV care resources, and access to ongoing training following the program. If our preliminary findings hold true in longer studies with more clinicians, this model may be adapted in other AETCs in the United States, as well as in other national and international training infrastructures. To date, the model has been shared with other AETCs and at least two have adapted the CSP approach into current or proposed programs. The National HIV/AIDS Strategy specifically called for workforce development in HIV clinical care to meet the needs of the emerging epidemic in the United States (The White House Office of National AIDS Policy, 2010). The CSP successfully targeted and engaged inexperienced front-line HIV clinicians who were either minority members themselves or who served minority communities. Clinicians participated in the program while working in their own practice settings, linked to clinical mentors and multidisciplinary caregivers. At a time when the United States is facing an aging HIV clinical workforce, it is encouraging to know that the CSP predominantly attracted clinicians who were 49 years of age or younger when they entered the program. Each of the five explicit priorities of the CSP (i.e., individualization, intensive mentoring, personal linkages, longitudinal training, and training within the local context) was reflected in the overall outcomes. In contrast to single training activities with didactic content where durable impacts/outcomes regarding improvements in clinical practice have been disappointing (Bradley-Springer, Everett, Rotach, & Vojir, 2006; Horberg et al., 2012), longitudinal mentoring in HIV care has been associated with the best training and learning outcomes (Mill et al., 2014; Workneh et al., 2013). CSP developed the mentor/learner relationship in real time within participant care settings, greatly increasing the likelihood of ongoing mentoring

11

and clinical consultation after the year-long program ended. Individualization of the training program enabled a rational selection of training activities suited to current levels of participant experience and focused on remedying important gaps in skills and HIV clinical knowledge. Clinician Scholars were invested partners and active planners in their own professional development, an approach that has been associated with improved learning outcomes in several studies (Bradley-Springer et al., 2006; Culyba et al., 2011; Davis et al., 1999; Rosen et al., 2005; Solomon et al., 2011). The CSP required all Clinician Scholars to participate in standardized elements during the course of the program to counter-balance the risk that heterogeneity within the curriculum would lead to incomplete training experiences for some. These standardized elements included a 1-day skill-building workshop at the start of the program, a focus on mastering core capabilities, clinical participation or observation, Webinars, and evaluation activities. Particular attention was also given to the personal dimension of HIV clinical care and learning. Mindful of the high rate of burnout among HIV clinicians, the CSP provided ongoing support to the individual Clinician Scholars and connections to a network of colleagues within the field to help ensure a high level of comfort and satisfaction while participating in the program. This was accomplished through close Monitor attention, clinical guidance and support from Mentors, and many contacts with multidisciplinary members of the HIV care network and the MATEC State Site staff. The longitudinal nature of Mentor relationships in the context of the Clinician Scholar’s own practice setting were critical to the support and engagement of participants, who understood that the CSP was committed to their learning as well as their well-being as learners and caregivers. More than half of the Clinician Scholars subsequently engaged in additional professional development (data not shown) following CSP completion. Clinician Scholars obtained added benefits from progressive engagement in their local HIV care networks because their abilities to provide care for PLWH improved as they acquired more clinical experience and resource contacts within their local networks.

12 JANAC Vol. -, No. -, -/- 2015

Having both self-reported and Mentor-reported competency assessment data offered a useful comparison, as well as a counter-balance to either measure alone. At baseline, the participants’ selfassessments were low; they may have been more self-critical and/or more honest about their own deficiencies. In contrast, after a year of working with a program participant, the Mentor may have been a more dispassionate source of information about an individual’s competency. In our data, there were substantial and statistically significant increases in self-reported competency across all domains. The Mentors’ interim 6-month assessments showed moderately high competency in many domains, so only modest improvements were observed at the 12-month mark. The high level of concordance between the endpoint evaluations of the Mentors and the self-evaluations of the program participants, each of which lent credibility to the other, was of considerable interest. The CSP faced many challenges. Recruiting primarily young, busy clinicians in complicated care settings to commit to a year of complex HIV training without remuneration was initially difficult. After 4 years, recruitment has improved as awareness of the program has grown through positive word-ofmouth feedback from CSP graduates. Similarly, the structure of the CSP evolved over time, with a few false starts. The heterogeneity of participant disciplines, individualized training plans, and varying degree of resources available to each State Site added to the challenges of creating a uniform program across the region and, in particular, to the development of standardized evaluation tools and criteria. The future scalability of the CSP is a continuing concern given the ever-increasing demand for new HIV clinicians in the region. Clearly, there is an urgent need to know the dimensions of this problem and to address it effectively. While the recommendations in the National HIV/AIDS Strategy to increase the workforce are a welcome start, the lack of resources, needed central coordination and oversight from federal and state agencies, and inadequate political will are major obstacles to an intensive, coordinated response to this need. Due to limited workforce data at the federal and regional levels, estimating the future need for HIV clinicians remains a

challenge for AETCs. Equally challenging is the need for ongoing funding to expand this intensive, learner-driven intervention. There were a number of limitations in our intervention, data, and analyses. Due to the relatively small sample size and the short duration of the program, these results must be considered preliminary. Enrollment was intentionally kept low to allow for intensive mentoring of participants. Program evaluation rather than formal hypothesis testing or generalization was the objective of collecting and analyzing these data. Participants in the CSP were carefully screened and selected rather than chosen at random. Given the sample size and the intentional selection of participants, the assumptions of statistical testing cannot be met. Our data were taken from only 20-25 of the 55 participants who had completed the program so far and may not represent the entire group. The instruments used to measure outcomes were developed as the program rolled out, based on preselected skill and learning objectives. Nevertheless, we are confident that our findings reflect actual trends that support improved competency as shown by Clinician Scholar self-assessment and Mentor ratings on trainee acquisition of capabilities. Self-reported assessment requires truth telling by participants; with the relatively small number of participants in this analysis, even a modest amount of misrepresentation could skew the results. Evidence to counter this concern was shown in the consistent strength of the effect as seen in all measurement domains for all participants and, with few exceptions, in Mentor assessments. It is unlikely that erroneous selfreporting drove the observed outcomes. In addition, there was strong concordance in the data and the availability of a second source of assessment added strength to the self-report data. Another potential limitation was observer bias: Mentors evaluating Clinician Scholars may have had a vested interest in having successful outcomes, and so may have overestimated participant performance competencies in one or more domains. Again, concordance of Mentor and Clinician Scholar ratings suggests that observer bias was not a significant issue. While more direct assessment of knowledge changes during the course of the program may have been useful, we instead focused on skill/capability

Boehler et al. / The MATEC Clinician Scholars Program

acquisition and implementing changes learned in practice settings. Future programs may include more pre- and postmeasures; however, concern about data burden for participants will also need to be considered. Because this was a training and service project, an in-depth research-based evaluation of actual improvements in prevention activities or diagnosis and treatment efforts for HIV-infected patients was not possible. Future evaluations of this type of program may include periodic direct observation of provider practice, patient simulation ratings, or periodic chart reviews of participant practices. Participant intake and exit interviews are still under analysis; when completed, these analyses will provide greater detail and content from the Clinician Scholars. More study is needed to further define the key clinical competencies on which the CSP should focus and the best practices for how to effectively teach those competencies. Decisions about the composition of the CSP curriculum were based on pragmatic factors rather than on objective or established instruction standards. For example, our requirement to participate in a minimum of 12 hours of clinical participation or observation arose from a blend of what was considered necessary and what was deemed achievable. It is worth noting that the average duration of clinical participation exceeded the 12-hour minimum threshold by 80%, and appeared to be limited more by time availability within a clinic or on the part of the Mentor than by participant interest. Clearly, the objectives of the program to reach front-line HIV clinicians in areas serving minority patients have begun to be met, as has the goal to improve the skills of those clinicians’ key domains of HIV care. However, the real number of newly trained front-line HIV clinicians needed likely exceeds the number trained by threefold or more (Sherer, 2012). Given the rapid rise in the number of PLWH in the United States, and the limited number of experienced HIV clinicians, further expansion and scale-up of the CSP will be needed to meet current and future needs in the region. The future of HIV care will continue to require clinical expertise that draws from and is matched with community needs and context where PLWH reside. The CSP is a model within an existing

13

AETC, which tailors and contextualizes meaningful learning experiences for participants without taking them away from existing care and support activities. Efforts need to continue to document program satisfaction, outcomes, and costs, as well as longterm program benefits to the participants, as well as to individuals living with HIV in the communities served.

Key Considerations  A 1-year individualized Clinician Scholars longitudinal mentoring program focusing on HIV knowledge and skills within the local and regional context succeeded in engaging minority and minority-serving clinicians and improving their abilities to diagnosis, treat, manage, and prevent HIV disease.  Significant improvement was shown in 11 core capabilities as measured by individual selfassessments and mentor reviews.  A multimodal and multidisciplinary adult learning approach within the existing AIDS Education and Training Center offered emerging clinicians working in front-line HIV care settings to improve clinical skills through linkages to state- and region-wide clinical experts, access to local and regional HIV care resources, and access to ongoing training following the program.  The Clinical Scholars Program provided ongoing support to the individual scholars and connections to a network of colleagues within the field to help ensure a high level of comfort and satisfaction while participating in the program.

Disclosures The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

14 JANAC Vol. -, No. -, -/- 2015

Acknowledgments This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H4AHA00062, AIDS Education and Training Centers, through the Minority AIDS Initiative. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government. The authors thank Michelle Agnoli, MSN, ACRN, Cheryl Carter, BSN, CIC, Catherine Creticos, MD, Alicia Downes, LMSW, Mary Rose Forsyth, MSN, NP, Sally Neville, MSN, Carolyn Prim, BA, Erin Smith, MPH, Suzanne CarlbergRacich, MPH, PhD, and Amanda Wilkins, MPA, for their efforts in developing the intake process, contributing to content and curriculum development, and envisioning the follow-up, monitoring, and completion elements of the MATEC Clinician Scholars Program. The authors also thank Jonathan Cohn, MD, MS, FACP, FIDSA, of Wayne State University; Alan Lifson, MD, MPH, of the University of Minnesota; Suellyn Sorensen, PharmD, BCPS, formerly of Clarian Health Partners; Jeff Meier, MD, of the University of Iowa; Patrick Tranmer, MD, MPH, of the University of Illinois at Chicago; and James Sosman, MD, of the University of Wisconsin for providing clinical leadership contributing to the development of the Clinician Scholars Program, constructing Objective Structured Clinical Examinations and acting as mentors to Clinician Scholars. Additionally, the authors express thanks to all of the site directors, program managers, and staff at the local performance sites not mentioned above who support MATEC efforts to enhance the capacity of HIV clinical services and improve the quality of those services for people living with HIV in the Midwest.

References AETC National Evaluation Center. (2015). AETC Cross-Region Evaluation (ACRE). Retrieved from https://aetcnec.ucsf.edu/ aetc-cross-region-evaluation-acre. American Academy of HIV Medicine. (2010). About. Retrieved from http://www.aahivm.org/about.

American Academy of HIV Medicine & HIV Medicine Association. (2009). Averting a crisis in HIV care: A joint statement of the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) on the HIV medical workforce. Retrieved from http://www.idsociety.org/ uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_ and_Issues/Workforce_and_Training/Statements/AAHIVM%20 HIVMA%20Workforce%20Statement%20062509.pdf. Bashook, P. G., Linsk, N. L., Jacob, B. A., Aguado, P., Edison, M., Rivero, R., . Prabhughate, P. (2010). Outcomes of AIDS Education and Training Center HIV/AIDS skillbuilding workshops on provider practices. AIDS Education and Prevention, 22(1), 49-60. Bradley-Springer, L. A., Everett, M. R., Rotach, E. G., & Vojir, C. P. (2006). Changes in clinician ability to assess risk and help patients determine the need for HIV testing: A comparison of three teaching methods. Evaluation & the Health Professions, 29(4), 367-393. Centers for Disease Control and Prevention. (2013). HIV surveillance report, 2011. Retrieved from http://www.cdc. gov/hiv/pdf/statistics_2011_HIV_Surveillance_Report_vol_ 23.pdf. Clinton Foundation. (2007). Clinical mentorship program: Predeparture readiness for volunteers. Retrieved from http:// www.catie.ca/pdf/CANAC/2007/Thomas%20-%20Clinical% 20Mentorship%20Program.pdf. Cook, P. F., Friedman, R., Lord, A., & Bradley-Springer, L. A. (2009). Outcomes of multimodal training for healthcare professionals at an AIDS Education and Training Center. Evaluation & the Health Professions, 23(1), 3-22. Culyba, R. J., McGee, B. T., & Weyer, D. (2011). Changing HIV clinical knowledge and skill in context: The impact of longitudinal training in the Southeast United States. Journal of the Association of Nurses in AIDS Care, 22(2), 128-139. Davis, D., O’Brien, M. A., Freemantle, N., Wolf, F. M., Mazmanian, P., & Taylor-Vaisey, A. (1999). Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Journal of the American Medical Association, 282(9), 867-874. D’Eon, M. F., & Trinder, K. (2014). Evidence for the validity of grouped self-assessments in measuring the outcomes of educational programs. Evaluation & the Health Professions, 37(4), 457-469. Enriquez, M., Farnan, R., Cheng, A., Almeida, A., Valle, D. D., Pulido-Parra, M., & Flores, G. (2008). Impact of a bilingual/ bicultural care team on HIV-related health outcomes. Journal of the Association of Nurses in AIDS Care, 19(4), 295-301. Health Resources and Services Administration. (2009). Training HIV/AIDS clinicians: 2008-2009 AETC report. Retrieved from http://hab.hrsa.gov/abouthab/files/aetcreport200809.pdf. Health Resources and Services Administration. (2014). Ryan White HIV/AIDS Program fact sheet: Part F: AIDS Education and Training Centers. Retrieved from http://hab. hrsa.gov/abouthab/files/partfaetcfacts2014.pdf.

Boehler et al. / The MATEC Clinician Scholars Program HealthHIV. (2015). Education & training. Retrieved from http:// www.healthhiv.org/what-we-do/education-training/. HIV Medicine Association. (2012). Minority clinical fellowship. Retrieved from http://www.hivma.org/Minority_Clinical_ Fellowship.aspx. Horberg, M. A., Hurley, L. B., Towner, W. J., Allerton, M. W., Tang, B. T., Catz, S. L., . Quesenberry, C. P. (2012). Influence of provider experience on antiretroviral adherence and viral suppression. HIV/AIDS – Research and Pallitative Care, 4, 125-133. Huba, G. J., Panter, A. T., Melchior, L. A., Anderson, D., Colgrove, J., Driscoll, M., . Zalumas, J. (2000). Effects of HIV/AIDS education and training on patient care and provider practices: A cross-cutting evaluation. AIDS Education and Prevention, 12(2), 93-112. Illinois Department of Public Health. (2013). Illinois HIV/STD monthly surveillance update. Retrieved from http://www. idph.state.il.us/aids/Surv_Report_1213.pdf. International Association of Providers of AIDS Care. (2014). IAPAC brochure. Retrieved from http://www.iapac.org/ uploads/IAPAC_Brochure_Web.pdf. International Training and Education Center for Health. (2011). Health workforce development. Retrieved from http://www. go2itech.org/what-we-do/health-workforce-development. Lalonde, B., Uldall, K. K., Huba, G. J., Panter, A. T., Zalumas, J., Wolfe, L. R., . Melchior, L. A. (2002). Impact of HIV/AIDS education on health care provider practice: Results from nine grantees of the Special Projects of National Significance Program. Evaluation & the Health Professions, 25(3), 302-320. Linsk, N. L., Carr, A., & Schechtman, B. (1997). Evaluation of AIDS Education and Training Center clinical training. Journal of Continuing Education in the Health Professions, 17(3), 163-172. Linsk, N. L., Mitchell, C. G., Despotes, J., Cook, J., Razzano, L., Grey, D., & Wolf, M. (2002). Evaluating HIV mental health training: Changes in practice and knowledge for social workers and case managers. Health & Social Work, 27(1), 67-70. Mill, J., Caine, V., Arneson, C., Maina, G., Padua, A. D., & Dykeman, M. (2014). Past experiences, current realities and future possibilities for HIV nursing education and care in Canada. Journal of Nursing Education and Practice, 4(5), 183-198. Mulligan, R., Seirawan, H., Galligan, J., & Lemme, S. (2006). The effect of an HIV/AIDS educational program on the knowledge, attitudes, and behaviors of dental professionals. Journal of Dental Education, 70(8), 857-868. National Alliance for HIV Education and Workforce Development. (2014). Recommendations for the AIDS Education and Training Centers (AETCs). Retrieved from http://www. aidsetc.org/sites/default/files/resources_files/NAHEWD%20 White%20Paper%20final%20May%202014.pdf. Rosen, D., Abedini, B. R., Jean-Baptiste, R., Richetti, D., Youngblood, A., & Spooner, L. (2005). Multi-discipline HIV longitudinal training: Utilizing AETC resources to build

15

HIV care capacity in minority-serving health centers. Journal of HIV/AIDS & Social Services, 4(2), 57-77. Saha, S., Komaromy, M., Koepsell, T. D., & Bindman, A. B. (1999). Patient-physician racial concordance and the perceived quality and use of health care. Archives of Internal Medicine, 159(9), 997-1004. Saha, S., Korthuis, P. T., Cohn, J. A., Sharp, V. L., Moore, R. D., & Beach, M. C. (2013). Primary care provider cultural competence and racial disparities in HIV care and outcomes. Journal of General Internal Medicine, 28(5), 622-629. Saha, S., Sanders, D. S., Korthuis, P. T., Cohn, J. A., Sharp, V. L., Haidet, P., . Beach, M. C. (2011). The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care. Patient Education and Counseling, 85(3), e278-e284. Samji, H., Cescon, A., Hogg, R. S., Modur, S. P., Althoff, K. N., Buchacz, K., . Gange, S. J. (2013). Closing the gap: Increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS ONE, 8(12), e81355. Sherer, R. (2012). The future of HIV care in the USA. Sexually Transmitted Infections, 88(2), 106-111. Sohler, N. L., Fitzpatrick, L. K., Lindsay, R. G., Anastos, K., & Cunningham, C. O. (2007). Does patient-provider racial/ ethnic concordance influence ratings of trust in people with HIV infection? AIDS and Behavior, 11(6), 884-896. Solomon, P., O’Brien, K., Hard, J., Worthington, C., Zack, E., & Gopee, N. (2011). An HIV mentorship programme for rehabilitation professionals: Lessons learned from a pilot initiative. International Journal of Therapy & Rehabilitation, 18(5), 280-289. Sullivan Commission. (2004). Missing persons: Minorities in the health professions. Retrieved from http://www.aacn.nche. edu/Media/pdf/SullivanReport.pdf. The White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States. Retrieved from http://www.whitehouse.gov/sites/default/files/uploads/ NHAS.pdf. U. S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2013). The U.S. health workforce chartbook. Retrieved from http://bhpr.hrsa.gov/health workforce/supplydemand/usworkforce/chartbook/chartbook part1.pdf. Workneh, G., Scherzer, L., Kirk, B., Draper, H. R., Anabwani, G., Wanless, R. S., . Tolle, M. A. (2013). Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana. AIDS Care, 25(1), 11-19.