HIV Education for Primary Care Advanced Practice Nurses and Students

Elizabeth Fletcher DNP, RN, APNC

Key Words: advanced practice nurses, HIV, knowledge and attitude, primary care nurse

practitioners

Financial disclosures: Grants/Research Support: None

Speakers’ Bureau: Gilead Sciences, Practice Point Communications, Janssen

Other Financial or Material Support: None

HIV EDUCATION FOR PRIMARY CARE ADVANCED PRACTICE 2

Abstract

Due to a lack of formal Human Immunodeficiency Virus (HIV) education many primary care

providers (PCPs) are not adequately prepared to provide care to people living with HIV (PLWH)

or HIV prevention measures for non-infected patients at risk for infection. Perceptions among

PCPs that they lacked formal HIV knowledge led to attitudes of frustration, and unwillingness to

provide care (Barnes.et.al., 2014). Relf and Harmon (2016) found that the entry-level

competencies of primary care advanced practice nurses (APN) do not adequately prepare them to

provide care to PLWH. The project utilized content available from the Acquired

Immunodeficiency Syndrome (AIDS) Education and Training Center (AETC) (Appendix A) to

develop, implement and evaluate an online educational resource for improving primary care

APNs and APN students’ (HIV) knowledge and attitudes. Pre-and post- intervention analysis

showed significant increases in HIV related knowledge and attitude.

Introduction

People living with and people at risk for HIV require PCPs who are knowledgeable of the

disease process and are comfortable providing HIV-related care. Barnes, Koester, & Waldura,

(2014) examined the attitudes of primary care providers towards caring for PLWH and found

that recently trained primary care providers did not feel that they were adequately prepared to

care for PLWH due to a lack of formal HIV training. Barnes and colleagues (2014) found that

perceptions among PCPs that they lacked the knowledge to provide care to PLWH led to

attitudes of frustration, difficulty, and reluctance that resulted in unwillingness to provide care to

PLWH. In a study that looked at knowledge, attitudes, practice and perception Delobelle,

Rawlinson, Ntull, Malatsi, Decock and Depoorter (2009) found a statistically significant positive

correlation between attitude, knowledge and training.

The core curriculum for APNs is necessarily broad-based and forms the foundation for all

graduate nursing education irrespective of specialty. Relf & Harmon (2016) examined the entry-

level competencies of primary care nurse practitioners (NPs) and found that although NPs obtain

knowledge and skills to practice safely, providing care to patients with HIV requires additional

education or specialization in HIV care due to the complexity of the disease and treatment. Relf

and colleague (2016) identified the need to integrate HIV concepts into basic NP curricula.

The simplicity, tolerability and efficacy of today’s antiretroviral treatment (ART)

regimens have decreased the incidence of Acquired Immunodeficiency Syndrome (AIDS),

defined by a weakened immune system that puts patients at risk for opportunistic disease and

death. With contemporary treatment PLWH experience a significant increase in life expectancy

as well as increased incidence in additional medical conditions due to aging and adverse effects

of ART. As patients are living longer with HIV, their care requires a team of healthcare

providers who are competent to care for the disease, the adverse effects of ART as well as the

co-morbid conditions of an aging population (Kwong, 2013).

PCPs need to be able to recognize signs and symptoms of acute HIV infection and to

integrate the Centers for Disease Control and Prevention (CDC’s) 2006 recommendation for

screening into their practices. The National HIV AIDS Strategy 2020 (2015) goal one focuses

on the prevention of new HIV infections among people at risk with implementation of evidence-

based prevention approaches that include pre-exposure prophylaxis (PrEP), post exposure

prophylaxis (PEP), counseling, testing and immediate linkage to care and treatment for those

who test positive. The NHAS 2020 goal 2A focuses on the integration of HIV testing,

prevention, care and treatment services into primary care (National HIV/AIDS Strategy 2020

(NHAS 2020), 2015). Wong et al., (2013) found that many PCPs are unaware of the 2006

recommendation by the Centers for Disease Control and Prevention (CDCP) that all patients

should be screened at least once and further screening should be based on the patient’s risks.

Aims and Objectives

The aim of this capstone project was to provide an online educational resource for HIV

education that was comprehensive and easily accessible for APN students and busy APNs in

primary care settings. The objectives were: a) Implement and evaluate an online educational

resource for improving PCPs knowledge and attitudes towards providing care to PLWH. b)

Compare the pre-and post-intervention knowledge utilizing a within-group pre-test/post-test

survey design. c) Assess the association between knowledge and attitude of APNs and APN

students towards PLWH.

Purpose of the study

The purpose of this practice improvement project was to develop, implement and evaluate an

online educational resource for improving primary care APNs’ Human Immunodeficiency Virus

(HIV) knowledge and attitudes. The study question was: Can an online HIV educational

program increase primary care APNs’ knowledge of HIV thereby leading to positive changes in

attitudes towards the care of People Living with HIV?

Review of the literature

A review of the literature was conducted that focused on the knowledge, attitudes and

ability of NPs to provide primary care for HIV infected patients and on the effect of online or

computer based learning. Databases searched were Medline, PubMed, Cumulative Index of

Nursing and Allied Health Literature (CINAHL) and Nursing and Allied Health Database.

Delimiting terms and phrases included HIV, AIDS, Primary Care, NPs, Nurse Practitioner,

APNs, Advanced Practice Nurses APN Competencies, Knowledge and Attitudes.

Theoretical Framework

Benner’s theory, novice to expert (Benner, 1982), was applicable as the APN in primary

care may be unprepared for the care of PLWH and attempt to educate themselves, gain

knowledge and apply it in everyday practice. The theory consists of five levels experienced by

the nurses as they gain knowledge and transition from novice to expert. The levels are: a)

novice, b) advanced beginner, c) competent, d) proficient and e) expert and can be viewed as a

continuum along which the APN moves as knowledge and experience are gained.

Methods

The literature review revealed gaps in the core curriculum of APN training of HIV-

related content, and experienced PCPs remain uncomfortable in the care of HIV-infected patients

and prefer to defer care to the HIV specialists. However, segments of the patient’s care require

the knowledge and care of the PCP (Barnes, Koester, & Waldura, 2014). This project aims to fill

education gaps in primary care APNs HIV knowledge utilizing tools and content from the AETC

The AIDS Education and Training Center was established in 1987 by Health Resource

and Services Administration (HRSA) and is administered through the Ryan White

Comprehensive Care Program, which funds care and treatment for people infected with HIV.

The program incorporates consultation and technical assistance from leading experts in the field

of HIV to provide evidence-based education to support healthcare providers and organizations in

providing care to people with HIV. Permission was obtained via email to utilize content from

the AETC’s website and to streamline it into a smaller easier to navigate website that is geared

toward the nurse practitioner in primary care.

The website was divided into three sections. One section contained the educational

intervention labeled HIV Education for Advanced Practice Nurses in Primary Care. Registration

was required to enter this section and an email address and password allowed participants to

reenter the site. There were six modules in the educational intervention. These included a

module that contained objectives, disclosures and an accreditation statement. Four modules

contained the educational intervention and the last module contained the survey monkey links to

the post-intervention and knowledge, attitude and practice surveys. The four topics covered in

the intervention were:

1. HIV Testing and Assessment

2. Healthcare Maintenance and Disease Prevention

3. Comorbidities, coinfections and complications

4. Antiretroviral (ARV) Interactions and Adverse Events

The other two sections of the website contained a clinical guide that is more expansive

than the education contained in the intervention and HIV Web Study and Case Definition. These

were designed by the AETC staff as resources for clinicians with questions related to HIV.

Website Evaluation

A five-member committee made up of two HIV care providers, two primary care APNs,

and a computer web designer were assembled to provide an analysis of the usability of the site

per the Perceived Health Website Usability Questionnaire (PHWUQ). The scale was developed

to test the usability of health websites designed for older adults. The tool was validated in the

study by a team of professionals as well as a group of older adults and showed good evidence of

internal consistency (.90-.92) (Nahm, Preece, Resnick, & Mills, 2004, p. 84). Prior to

implementation of the project, a Survey Monkey questionnaire was emailed to the committee

members asking them to rate the site for readability, presentation of information, and ease of

navigation. Rating was done on a Likert scale ranging from strongly disagree (1) to strongly

agree (5). Everyone responded to the survey questions with agree to strongly agree with

appearance of the site, graphic display and ease of information having the lowest rating. Ease of

finding information and relevance to practice were given the highest scores. No member reported

difficulty accessing the site or being locked out of the site. Written feedback and suggestions

were acted upon promptly.

Recruitment

Collaborative Institutional Training Initiative (CITI) training for the protection of human

subjects in research was required and obtained. Institutional Review Board (IRB) approval was

obtained from Rutgers University for the original criteria of male and female APNs providing

primary care of adults. After six weeks of slow enrollment, IRB approval of the modification to

include APN students was sought and attained.

Participants were recruited from local and national organizations, universities and social

media sites like LinkedIn and Facebook. The recruitment invitation included the survey monkey

links to the demographic (Appendix B) and pre-intervention surveys as well as the link to the

educational intervention. The survey monkey links to the post-intervention survey as well as the

knowledge, attitude and practice survey were embedded in the educational intervention. The

CNE certificate displayed after completion of the post intervention surveys. Consent for the

project was implied by participation. As this was an online project, participants could access the

site from any device with internet capability.

Results

The demographic survey was completed by 126 participants but only 119 completed the

pre-intervention survey, of these 84 signed in to the education, 64 met the criteria and completed

the project. Of the participants 19 identified as students and 45 as APNs working in some aspect

of primary care.

The knowledge, attitude and practice survey was graded on a Likert scale rated from 1

(poor/ not willing) – 5 (excellent/ very willing) and consisted of six questions related to:

knowledge, willingness to provide care and application to practice. A paired samples t test

comparison of the pre-and post-level knowledge was calculated. Pre-intervention M: 2.4

(sd=1.144) and post-intervention M: 3.91 (sd=.771). A significant increase was found in the post

intervention knowledge level (t(63)=-11.880, p<.001). A paired samples t test was also

calculated to compare the mean pre-intervention score on attitude (willingness to care) to the

post-intervention score. Pre-intervention M: 2.88 (sd=1.30) and post-intervention M: 3.95

(sd=.880). A significant increase was found from pre-intervention attitude to post- intervention

attitude (t(63) =-9.099, p<.001).

Spearman’s rho correlation coefficient was calculated for the association between

participant’s knowledge of HIV and their willingness to care for PLWH (attitude). A moderate

positive correlation was found pre-intervention: (rho(64)= .438, p<.001) and post-intervention:

(rho (64) =.482, p<.001)

Spearman’s rho correlation coefficient was calculated for the association between work

experience (grouped by number of years) and attitude before and after the intervention. No

significant correlation was found for the association between work experience and attitude before

the intervention (rho (63)= .-041, p .748) or after the intervention (rho (63) =0.51,p=.693

Discussion

Despite low project completion rate, comparison of pre- and post- intervention data

analysis showed a significant improvement in knowledge and attitude among APNs and APN

students. This finding supports the research suggesting that clinicians’ benefit from web based

learning modules. Furthermore, the fact that many participants initiated the intervention but did

not complete it demonstrates the need to identify ways to increase learner engagement.

The study had several limitations, first of which is the inability to reach the recruitment

goal of 128 participants resulting in a small sample size (64) that completed the project.

Despite analysis showing statistical significance, a larger sample would add power,

reliability and generalizability. Secondly, time to completion of the project appeared to have

been a limitation based on feedback from participants. The educational intervention took

approximately six hours to complete and awarded 6 CNEs at completion. Despite the ability to

earn CNEs project completion rate was low. Participants that completed the project found the

ability to earn CNEs an important inducer to participate, with 29% reporting taking the course

for the credits while 63% reported taking the course both for the credits and relevance to

practice.

Weaknesses related to the project design that, once addressed would strengthen the

interventions ability to be disseminated more widely include the inability to distinguish APNs in

practice from APNs in a DNP program who identified as student, as well as the inability to

distinguish RN to DNP students experience from APN’s practice experience. These limitations

affected the ability compare whether APN experience was associated with attitude. As

participants included APN students and APNs in practice the analysis was a correlation of

nursing experience and attitude. Lastly, online recruitment of participants proved to be time

consuming and costly. Many nursing associations require membership to the organization and to

fee to post the invitation to the website one or two times

While identifying and accounting for the limitations related to the project design and

sample size are appropriate it is imperative to note the fact that 75% (45) of participants thought

that they could apply the information learned in practice. Most of the clinicians who completed

the project reported that they found the education helpful; the website was easy to navigate and

would utilize the site as a resource in the future when caring for this patient population. It is also

worth noting that 88.3% (53) of the project participants rated the learning modules and project as

“good to excellent.”

The survey was sent to APN students and nurse practitioners through APN academic and

professional organizations but did not specifically target any racially identified academic or

professional group for inclusion but encouraged all participants. The majority of the project’s

respondents (81%) identified as Caucasian and 61% of the study participants identified as

practicing in suburban areas. Research has shown that HIV disproportionately affects Black and

Hispanic individuals in lower socioeconomic urban areas (CDCP, 2013). Providers caring for

urban dwellers are more likely to encounter HIV patients in their practices. This incidental

finding underscores the crucial need to ascertain ways of increasing outreach to these providers

as well as increasing their engagement in the health care needs of PLWH. Furthermore, the race

demographic data gathered in this project which supports the already identified racial disparity in

healthcare (ART-CC, 2013), this incidental finding reinforces the need to increase the presence

of minority providers as well as look for opportunities to build trust between the Caucasian

provider Black or Hispanic patient.

Age was also a major finding with the majority (56%) of respondents over the age of 50.

The HIV workforce study (Relf and Harmon 2016) also found that the average age of HIV care

providers was over 50 leading to a crisis in the HIV workforce and underscoring the need for

APN programs to train a younger generation of APNs with HIV knowledge that they can

integrate into their practices

Conclusion

HIV is considered a chronic disease that is rapidly moving into primary care clinics. The

complexity of HIV-infection requires healthcare providers who are knowledgeable about treating

the disease and offering prevention measures to those at risk for infection.

The study underscores the findings of Relf & Harmon (2014) that the entry level core

competencies do not adequately prepare APNs to care for PLWH and demonstrates the need for

integration of HIV related education into the APN curricula. The current state of the HIV

epidemic with a focus on prevention in non-infected people at risk for infection and the complex

care of PLWH requires that APNs in practice and graduating APNs are adequately prepared to

provide this care. The data obtained through this quality improvement project demonstrated that

the evidence based HIV educational website resulted in a change in knowledge that led to

improvement in attitude of APNs and APN students towards caring for PLWH. Knowledge

gained in this on line educational project can be integrated into the clinical practice of APNs in

the primary care setting and can strengthen the academic preparation of APN students prior to

licensure and increase their confidence as new APNs. The educational website will remain as a

resource for students and practicing APNs. The project has led to the identification of a need for

tailored outreach to providers in urban areas. Likewise, findings from this study may be used to

appreciate the need for more diverse racial profiles of health care providers.

Reference

Barnes, J., Koester, K. A., & Waldura, J. F. (2014). Attitudes about providing HIV care: Voices

from publicly funded clinics in California. Family Practice, 31, 714-722.

Benner, P., (1982). From novice to expert: The Dreyfuss model of skill acquisition. Journal of

Nursing, 82(3), 402-40

Delobelle, P., Rawlinson, J. L., Ntuli, S., Malatski, I., Decock, R., & Depoorter, A. M. (2009,

March, 2009) HIV/AIDS knowledge, attitudes, practices and perceptions of rural nurses

in South Africa. Journal of Advanced Nursing, 1061-1073. http://dx.doi.org/

doi:10.1111/j.1365-2648.2009.04973.x

Nahm, E. S., Preece, J., Resnick, B., & Mills, M. E. (2004, November/December). Usability of

health web sites for older adults: A preliminary study. CIN: Computers, Informatics,

Nursing, 22, 326-334.

National HIV/AIDS Strategy for the United States: Updated to 2020 . (2015). Retrieved from

http://www.cdc.gov/hiv/policies/nhas.html

Relf, M. V., & Harmon, J. L. (2016, May/June). Entry-level competencies required of primary

care nurse practitioners providing HIV specialty care: A national practice validation

study. Journal of The Association of Nurses in AIDS Care, 27, 203-213.

Spach, D. H., Wood, B. R., Karpenko, A., Unruh, K. T., Kinney, R. G., Roscoe, C., & Nelson, J.

(2016, May/June). Creating a national HIV curriculum. Journal of the Association of

Nurses in AIDS Care, 27(3), 261-273.

Wong, E., Jordan, W., Malebranche, D. J., DeLaitsch, L. L., Abravanel, R., Bermudez, A.,

& Baugh, M. P. (2013). HIV testing practices among black primary care physicians in the United

States. BMC Public Health, 13(96), 1-9. http://dx.doi.org/doi:10.1186/1471-2458

Appendix A

AETC Content

Section:2 Testing and Assessment

Initial History

Initial Physical Examination

Initial and Interim Laboratory and Other Tests

Interim History and Physical Examination

CD4 and Viral Load Monitoring

Risk of HIV Progression/Indications for ART

Early HIV Infection

Expedited HIV Testing

Section 3: Health Care Maintenance and Disease Prevention

Occupational Postexposure Prophylaxis

Nonoccupational Postexposure Prophylaxis

Preventing HIV Transmission/Prevention with Positives

Immunizations for HIV-Infected Adults and Adolescents

Preventing Exposure to Opportunistic and Other Infections

Opportunistic Infection Prophylaxis

Latent Tuberculosis Infection

1) Section 6: Comorbidities, Coinfections, and Complications

a) Dyslipidemia

b) Insulin Resistance, Hyperglycemia, and Diabetes on Antiretroviral Therapy

c) Coronary Heart Disease Risk

d) Renal Disease

e) Immune Reconstitution Inflammatory Syndrome

f) Candidiasis, Oral and Esophageal

Gonorrhea and Chlamydia

g) Herpes Simplex, Mucocutaneous

h) Herpes Zoster/Shingles

i) Pneumocystis Pneumonia

Section 7: ARV Interactions and Adverse Events

Adverse Reactions to HIV Medications

Drug-Drug Interactions with HIV-Related Medications

Antiretroviral Medications and Hormonal Contraceptive Agents

Appendix B: Demographic Questionnaire Code

Age (group)

1. 20 -35

2. 36 – 50

3. >50

total

Gender

1. Male

2. Female

3. Transgender

total

Race

1. Black/African American

2. Hispanic/Latino

3. White, not of Hispanic origin

4. Asian/Pacific Islander

5. American Indian/Alaskan

6. Another race/ethnicity

7. Multiracial ethnicity

total

Title

1. Student

2. APN

total

Work Experience (group years)

1. <2

2. 2 – 10

3. 11 -20

4. 21 -30

5. >30

total

Wok setting

1. FQHC

2. Health Center (not FQHC)

3. Patient Centered

Medical/Healthcare Home

4. Hospital based primary care

practice

5. Private practice

6. Other ____________

total

N /%

26 /21

43/34

57/45

126

9/7.2

116/93

0/0

125

14/11

1/1

101/80

10/8

0/0

0/0

0/0

126

19

97

126

25/20

31/25

24/19

23/19

21/17

124

6/4.5

11/8.7

12/9.5

26/20.6

23/18.3

10/7.3

38/30.2

125

Work hours

1. < 10

2. 10 – 20

3. 21 – 30

4. >31

total

Primary site is

1. rural,

2. suburban,

3. urban

total

.Ever worked in HIV /AIDS specialty care?

1. Yes

2. No

total

HIV Experience (how long)

1. < 1year

2. >1 year

total

Reason for taking course

1. This course is relevant to my

practice

2. I am taking the course for the

educational credits

3. Both

total

N/%

27/23

10/8.2

11/9.1

73/60.

121

17/14

73/59

27/33

117

12

112

124

6

6

12

10/7.9

37/29

79/63

126