Associate Professor Jason Farley and his crew chart a course toward a future where nurses lead HIV/AIDS care. Their vessel is now accepting passengers.
The 31-year-old Moore Clinic operated by the Johns Hopkins AIDS Service at the School of Medicine is a historic operation—the second-oldest AIDS clinic in the country. But when Jason Farley, PhD, MPH, CRNP, looks nowadays at the makeup of Moore’s caregiving staff, he worries that he’s seeing too much history.
“There are 12 non-physician providers, and I am one of the two youngest. And I’ve been there for 11 years now,” notes Farley, an HIV/AIDS nurse practitioner at the clinic since 2003.
The situation is not isolated to specialty clinics like Moore. A 2014 survey sponsored by the nonprofit HealthHIV found that half of primary care physicians in the U.S. do not provide HIV care because they don’t feel qualified to do so. Of those who do offer care, most are physicians, and 55 percent are over age 50. “We really need to get new young people in,” says Farley, assistant professor at the Johns Hopkins School of Nursing.
HIV can’t tell physicians from nurse practitioners. Neither can studies that look at outcomes among patients treated by the two different groups. So, seeing an opportunity to innovate, the Hopkins School of Nursing developed a new HIV curriculum, launching in September as a specialized degree option within the Adult Geriatric Nurse Practitioner and MSN/MPH/AGNP programs. Those enrolled in these programs can earn an HIV Primary Care Certificate at the same time.
“For many years these specialty training programs in HIV have been available for physicians,” says Farley. “This is the first time we’re offering them to non-physician providers. It’s quite an important development. When you look at data comparing patient outcomes with physician care and with nurse practitioner care in HIV, whether in the United States or in sub-Saharan Africa, those outcomes are the same.”
One factor, Farley says, is that nurse practitioners routinely spend more time with patients than physicians do: “In many studies, we see that patient-provider interactions are especially strong with nurse practitioners, and that results in improved adherence by patients to their treatment regimens.”
The development of the HIV curriculum track is being financed by a five-year, $1.5 million grant financed by the Health Resources and Services Administration (HRSA).
Farley opted to place the Hopkins training module inside the nurse practitioner degree program in response to current trends in HIV care. Slowly but steadily, that care has been migrating into primary care settings and out of specialized clinics. The trend is likely to accelerate, both because HIV patients in this country continue to live longer, healthier lives than in years past and because the Affordable Care Act and other public policy efforts are seeking to link more HIV patients with health insurance and, hence, primary care providers.
“The design of our program starts with the recognition that HIV care cannot be provided in a silo, that it needs to be integrated holistically into primary care,” Farley says. “We want our students to get this training right at the same time they’re getting their advanced training in primary care.”
The new curriculum grew out of the application process for the HRSA grant, which made Hopkins one of four schools of nursing (of five awardees) to be funded as a National AIDS Education and Training Center. The Hopkins program is unique in the fact that it will offer the HIV certificate program to adult geriatric nurse practitioner students only.
The idea is to build an HIV care program that is sustainable beyond the five years of the grant. “There’s an overarching, societal benefit to treating and maintaining someone in HIV care,” Farley says. “Through this curriculum, students learn how to immediately take the latest findings of research in evidence-based practice and put them to use.”
Farley, Principle Investigator for the grant, also serves as clinical core co-director of the Johns Hopkins Center for AIDS Research, which seeks to develop and nurture a new generation of researchers with an emphasis on interdisciplinary work. He also has an adjunct appointment on the faculty at Stellenbosch University in Cape Town, South Africa. There, he is studying treatment outcomes for HIV-positive patients with multi-drug resistant tuberculosis on a grant funded by the National Institutes of Health. In the U.S., Farley is assessing the dangers posed to HIV/AIDS patients by the multi-drug resistant Staphylococcus aureas, or MRSA. And he is evaluating adherence in the Johns Hopkins AIDS Service to newly issued guidelines for cardiovascular care.
Time in the Field
One innovative twist in the new curriculum track extends the time students spend on field placements. Most nurse training programs operate on a semester model, but students on the HIV track will work in one location for an entire year.
“In the semester model, you may see a patient just twice before it’s time to move on, maybe three times at the most,” Farley says. “That makes it difficult to really know if you’re managing their hypertension well, for example, or their diabetes.”
The longer stay will put students and their physician preceptors in a better position to evaluate their work at the end of the placement.
“We are striving here to offer a continually reflective model of training,” Farley says. “That will be a big help to students when they get out in the field. They’ll be prepared to do the work of implementing interventions in ways where they can really measure progress going forward and see what’s succeeding and what they need to work on.”
Farley hopes to have as many as 20 sites where students will be working, ranging from specialty care rotations to prevention-oriented programs and primary care clinics. “I expect that the continuity of care that comes with the year-long HIV primary care schedule will have real productivity benefits for our field sites,” Farley explains.
Another key component of the program is a type of sensitivity training that pushes students to identify negative preconceptions they hold about the patient populations they’ll be serving, notions that could affect care. Early on, students will go out in the field doing “harm-reduction walks” that involve distributing condoms and health information to sex workers, as well as offering HIV testing.
“We really want them to reflect about what their preconceptions were and what the reality was,” he says.
Farley prefers the phrase “culturally relevant” to the more popular “culturally competent” when it comes to training students to deliver care to members of different social and cultural groups.
“If you see one transgendered patient during your training, that’s not going to make you ‘competent’ in caring for the transgendered,” he says. “But if we train you to be open and flexible and amenable, if we train you in the skill set you need to learn and understand and react to a new culture, that’s going to make you a better provider.”
Measures of Success
That “continually reflective” approach is not something that moves only in one direction, from teacher to student. It also moves in the opposite direction, most notably when faculty members seek input from students in evaluating the success of the new program and making improvements.
“Before they even go through an orientation, actually, we’ll be asking them about their expectations of the program, and about what they see as gaps in their knowledge and training they need,” says Assistant Professor Caroline Fowler, PhD, MPH. “The philosophy that we are embracing here is multilayered. It’s one in which everything we do in the program, from the selection of students to post-graduation follow-up with them, provides us with an opportunity to learn about what we’re doing and about how to do it better.”
The First Class
Farley expects the new track to launch with an enrollment of eight to 10 and grow from there. Connecticut native Amit Dhir, who earns his BSN from the School of Nursing this summer, will be joining that first class after spending a couple of months abroad on a research project evaluating HIV/AIDS intervention strategies in South Africa.
Dhir’s journey toward the program began while he was studying for a master’s in business administration. He landed in an internship doing cash-flow reports at the Central Area Health Education Center, an HIV care facility in Hartford, CT with a focus on underserved patient populations.
“I was there for six months, and I was just so amazed at the care the nurse practitioners were providing to their patients,” Dhir says.
One thing that appealed to Dhir is the new curriculum’s focus on multidisciplinary approaches and treating patients in a holistic manner that goes beyond traditional clinical care and reaches across the psychosocial spectrum of their lives.
“Eventually, I want to work internationally, in places where they don’t have access to the medications that we do here,” he says. “I want to be a part of bringing to those places more access to the kind of normal lives that HIV-positive patients are living here in the West.”
That’s another quantifiable outcome that Farley and Fowler plan on tracking—the jobs students land upon earning their degrees. He expresses hope that many students will choose remain in the Baltimore and Washington regions, both of which rank in the top 10 in the country for both the number of individuals with HIV and the number of new infections per year.
But he is confident that wherever they land, they’re going to be ready to make a difference for patients and institutions alike.
“Our students at Hopkins are, bar none, some of the best in the country,” Farley says. “They’re really poised to make a difference in this field, and we want to make sure that happens.”
Assistant Professor Jason Farley says one reason he’s confident that the new HIV/AIDS degree program at the School of Nursing will draw plenty of interest from prospective students is that so many of the current students and alumni he’s met over the years arrive on campus with a strong interest in HIV.
“I’ve met students who have been Peace Corps volunteers in sub-Saharan Africa, or they’ve been working in harm-reduction programs with persons living with HIV in the District of Columbia,” he says. “I could go on and on.”
A current student, Willa Cochran, is a case in point. A former Peace Corps volunteer in the West African nation of Guinea, she worked before coming to Hopkins as a case manager for a New York City organization that supports HIV-infected immigrants from Africa and the Caribbean.
That experience is what sparked her interest in “social remittances,” the notion that many immigrants send much more back to their home countries than the wire transfers of cash. They send knowledge unavailable in developing nations. It’s a concept that’s often talked about in areas like financial literacy and educational achievement, but Cochran believes it has potential in healthcare as well.
“We’d be working with these women, and, completely unprompted, they’d report conversations they were having about HIV with family members back home,” Cochran says. “Some of them were sending condoms. Or they were talking about the importance of getting tested before marriage.”
At Hopkins Nursing, Cochran earned her bachelor’s degree, and she’s now in the HIV Primary Care Certificate program as she works toward becoming a nurse practitioner. Along the way, she won a Provost’s Undergraduate Research Award for taking her preliminary notions about social remittances and turning them into a successful proof-of-concept study. Over three days back in New York, she interviewed 28 immigrant women from 16 African nations and found that they were indeed relaying information and advice about HIV and AIDS to family members and friends back home.
“They’re uniquely positioned to do so, too,” Cochran says. “These are women who have gained a lot of knowledge in migrating here. They’ve also gained social power and prestige, so they have the ability to deliver messages in particularly powerful ways.”
Cochran, who hopes to one day work in a primary care setting that serves both HIV patients and immigrants, thinks this notion of “social remittances” deserves more attention from researchers and practitioners alike. “When you’re a nurse and you’re talking with an immigrant patient, the audience you’re speaking to could potentially include a sister back home, a whole family, friends—and through that, an entire village,” she says.