The goal was to establish a pathway to train future practitioners to provide competent care for PLWH and persons identifying as LGBT.
Our program objectives were:
To establish a new match for residents in an HIV PCT
To identify a core faculty of preceptors with expertise in HIV medicine and LGBT health
To recruit at least 20 HIV-infected patients per resident as continuity patients
To develop a comprehensive curriculum addressing HIV and LGBT health for track residents
To prepare track residents for certification as HIV specialists
To develop objective structured clinical examinations (OSCEs) to formatively assess specialized skills
HIV PCT residents held their weekly continuity clinic at Fenway Health, with core faculty serving as preceptors. Residents were expected to establish a patient panel that included at least 20 PLWH. They were also given several references, including a locally produced HIV manual,14 the Fenway Guide to LGBT Health,15 the AAHIVM Fundamentals of HIV Medicine,16 and a subscription to AIDS Clinical Care. In addition to the standard HIV ambulatory care intern curriculum, HIV PCT residents participated in a weekly conference consisting of didactic, case-based discussions on HIV/LGBT care and related issues, including management of a new HIV diagnosis, starting ART, pre- and post-exposure prophylaxis, HIV resistance testing and managing virologic failure, sexually transmitted infections (STI), contraception and family planning, aging and HIV, addiction medicine, and primary care of LGBT patients. HIV PCT residents were also invited to a weekly interdisciplinary conference attended by primary care HIV practitioners, infectious disease specialists, and an HIV case manager, and completed online case modules developed by the International Antiviral Society—USA.17 In addition, outpatient electives in infectious diseases and HIV-related fields such as substance abuse and public health were encouraged, as was participation in a global health rotation in a high-HIV-prevalence region (e.g., Botswana). Finally, residents were required to complete a project culminating in a presentation at an academic meeting. Upon completing residency, participants were expected to take the AAHIVM certification exam. A curricular map is provided in Table 1.
We designed a comprehensive program evaluation in three domains—learner-centered, patient-centered, and institution-centered—along Kirkpatrick’s levels of evaluation (Table 2). The institutional review board at Fenway Health approved the project as quality improvement. Program evaluation metrics were largely descriptive rather than comparative: Track residents represented motivated trainees, which would have introduced self-selection bias if compared to a control group of residents. Additionally, HIV PCT residents’ clinic and assessment experiences had no equivalents in the categorical track.
To assess learner attitudes toward the curriculum, we conducted yearly surveys of resident perceptions and focus groups to assess resident satisfaction. The survey instrument was developed by program faculty in an iterative and collaborative manner and was piloted prior to use. Tabulation of survey results indicated that the majority of interns entering the program had career interests aligned with the goals of the HIV PCT, including a reported desire to practice primary care (88 %), infectious disease (63 %), HIV care (88 %), and care of an underserved population (88 %).
We conducted focus groups at the end of each academic year with open-ended questions focused on the educational and professional impact of the program. A thematic analysis of audio recordings from the focus groups identified several key motifs. Residents remarked on the uniqueness of the Fenway patients, which provided a vastly different perspective on HIV compared to previous experiences with PLWH. The opportunity to care for transgender patients in particular provided an unparalleled clinical experience, as summed up by one resident: “The specialized training I’ve got is in LGBT primary care, and the track should probably be renamed HIV and LGBT primary care.” Additionally, the HIV PCT had an unexpectedly path-shifting impact on residents’ careers. One resident articulated, “[It] altered [my career]. I wouldn’t have ever expected to work with this population when I was in med school. I would have said that I would have ended up still at a community health center but probably with a Hispanic population or inner city population. I never would have expected to start working with LGBT [individuals].”
We also assessed resident learning using the AAHIVM certification exam; seven of our first eight graduates took the exam, all of whom passed. To provide formative feedback to residents on their knowledge and skills, we held OSCEs at the end of each academic year. OSCE stations were thematically linked and increased in complexity across all years of training; topics included preconception/contraception, STIs, HIV management, and LGBT health. Resident OSCE scores from faculty and standardized patients were high; however, the cases allowed us to identify specific areas for resident improvement and curricular refinement. For instance, relatively poor performance by male residents on cases addressing women’s health needs led us to provide additional experiences for male HIV PCT residents in a women’s health clinic.
The program also successfully achieved a resident continuity patient panel size of 20 or more PLWH: on average, the panels of the eight HIV PCT graduates included 21.9 PLWH. Only one resident, who joined the track in her second year, graduated with a panel of 17 PLWH.
We examined the impact of our curriculum in various ways. First, we examined 2-year performance on several core HRSA HIV/AIDS Bureau measures18 (Table 3). HRSA has not published benchmarks for these measures and provides only comparison data that differ by cohort, methodology, and date range, depending on the specific quality measure. Overall, however, HIV PCT resident performance on assessed quality measures was broadly comparable to these published comparison group data.18 We also assessed patient satisfaction from PLWH who identified track residents as their primary practitioner, using an instrument extensively employed in our other clinics and modified for the Fenway population. Data tabulated from 120 surveys collected over 2 years showed that patients had high levels of satisfaction with the care their HIV PCT residents provided (see Online Appendix for more detailed results). To address our objective of developing a core faculty, we expanded the number of preceptors from 7 to 12, and broadened the resident training experience to a second Fenway Health site with new preceptors. Finally, we examined workforce development and found that six of our first eight HIV PCT graduates took positions in primary care involving care of PLWH.