Scope of Practice Intentions Among Family Medicine Residents for Integrated Care of HIV and Hepatitis C Infection in People With Opioid Use Disorder

People who inject drugs are at higher risk not only for opioid overdose but also for blood-borne infections, including human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections. In fact, injection drug use has been the most common risk factor for HCV infection and the second most common for HIV infection following sexual transmission. ^1-3

The HIV and HCV care continua have been challenging, especially among patients with a substance use disorder (SUD). ^3-5 A collaborative, multidisciplinary model approach did not improve linkage to care for HCV in patients with SUD in the outpatient setting. ⁶ Qualitative interviews with HIV and SUD care practitioners revealed challenges in communication across disciplines and transportation as barriers for HIV care among people living with HIV with comorbid SUD. ⁷ Of people living with HIV with SUD, those with high levels of medical mistrust and low education background had lower odds of early linkage to care. ⁸ Furthermore, in the United States, approximately 1.2 million people live with HIV and 2.5 million people live with current HCV (RNA positive), indicating the need for family physicians who can manage these conditions, especially given the limited access to infectious disease physicians in rural communities. ^9-11 To address those barriers, family physicians are well positioned to care for patients with HIV and HCV along with buprenorphine treatment for opioid use disorder (OUD), referred to as “integrated care” in the rest of our paper.

Prior research has described the suitability and characteristics of family physicians who provide each service, ^12-16 but no study has examined family physicians who provide integrated care. We sought to describe the individual and residency characteristics of graduating family medicine residents who intended to practice integrated care. We also compared the intended scope of practice between respondents who intended to provide integrated care and those who did not.

We used 2017–2021 data from the American Board of Family Medicine (ABFM) initial certification questionnaire. ¹⁷ The questionnaire is completed by graduating residents 3 to 4 months prior to the examination date as a required component of registration. The questionnaire asks whether, after residency, respondents intend to provide “buprenorphine treatment,” “pharmacological management of HIV/AIDS,” and “pharmacological management of Hepatitis C,” as well as asks about a series of services and procedures, future practice type, and participation in loan repayment programs. Race and ethnicity were self-reported by the residents in response to a select-the-best-answer question. Standard demographics (age, gender, degree type, medical school location) were obtained from the ABFM administrative data sets. We obtained county-level data on 2018 overdose mortality, derived from Centers for Disease Control and Prevention data, from the HepVu website. ¹⁸

Our primary outcome was whether the respondent said yes to intending to provide each of buprenorphine, HIV, and HCV treatments. We categorized respondents by whether they currently participated or planned to participate in incentive programs, including the public service loan forgiveness program and J-1 visa waiver. Rural residency status was assigned based on the Rural Medical Training Collaborative list. We measured community need for OUD treatment at the county level for the residency according to the opioid mortality rate (per 100,000 people) and categorized the need into high (≥30 per 100,000) or low (<30). ¹⁹

Because our study focused on integrated care of OUD, HIV, and HCV in the ambulatory setting, we limited our sample to graduating family medicine residents who intended to primarily provide outpatient continuity care. We excluded those who selected “unknown” in response to the question about their intended practice site after residency. We included only those from residencies with matching OUD mortality data.

First, we conducted bivariate analyses using χ² tests to compare the characteristics and scope of practice of those who intended to provide integrated care and those who did not. We then performed a single logistic regression analysis to assess independent associations of personal, future practice, and residency characteristics with providing integrated care.

We used SAS version 9.4 (SAS Institute) for all analyses. The American Academy of Family Physicians Institutional Review Board approved this study.

The response rate was 100% with 18,479 total respondents. Of the total respondents, we included 15,764 who reported that they planned on providing continuity care, and then from those, we excluded 4,958 respondents who did not know their intended practice site after residency. We also excluded 223 respondents whose residency did not have matching opioid overdose mortality data. After the exclusions, our final sample size was 10,583 (57.3%) of 18,479 respondents. Among respondents in our study, the average age was 32.1 years, 54.7% were female, 25.2% graduated from an osteopathic medical school (ie, DO), and 25.3% were international medical graduates. White and non-Hispanic people accounted for 64.4% and 91.0% of our final sample, respectively (Table 1).

Only 7.3% (774 out of 10,583) of residency graduates reported an intention to practice integrated care, 8.3% (883 out of 10,583) reported their intention to practice either HIV or HCV care in addition to OUD care, and 12.1% (1,283 out of 10,583) reported intending to provide only OUD care without HIV and HCV care (Table 2). In regression analyses, resident characteristics associated with lower odds of providing integrated care included female (adjusted odds ratio [AOR]=0.80; 95% CI, 0.66–0.98), DO (AOR=0.54; 95% CI, 0.35–0.82), international medical graduate (AOR=0.71; 95% CI, 0.53–0.93), Hispanic or Latinx (AOR=0.54; 95% CI, 0.36–0.80), or younger age. After residency, future practice sites with higher odds of providing integrated care included federally qualified health center or look-alike (AOR=2.27; 95% CI, 1.72–3.00), Indian Health Service (AOR=2.44; 95% CI, 1.16–5.10), and nonfederal government clinic (AOR=1.82; 95% CI, 1.05–3.16). Residency characteristics associated with more graduates intending to provide integrated care included rural program (AOR=1.55; 95% CI, 1.08–2.22), location in the Northeast (AOR=1.61; 95% CI, 1.17–2.22) or West (AOR=1.79; 95% CI, 1.34–2.38), and higher county-level opioid overdose mortality rate (AOR=1.51; 95% CI, 1.15–1.98). Intentions to provide prenatal care, behavioral care, intrauterine device insertion or removal, point of care ultrasound, chronic pain care, and osteopathic manipulative treatment were all positively associated with intention to provide integrated care (Table 3).

Despite the increasing need for family physicians who can provide comprehensive care of OUD and injection drug use-related blood-borne infections, only 7% of family medicine residency graduates in recent years reported their intention to provide such integrated care. Training in a county with higher opioid overdose mortality increased the odds of family physicians who planned to manage all three services. Family medicine residencies likely adjusted their curricula in response to community needs, and residents were then exposed to more patients requiring integrated care.

Our study revealed individual and residency characteristics of graduating family medicine residents who intended to provide integrated care of HIV and HCV for people with OUD. Our findings are important because family physicians play a critical role in taking care of people with OUD by providing integrated care for common comorbid conditions, including behavioral health and blood-borne infections. The Health Resources and Services Administration encourages an integrated care model of behavioral health and primary care for OUD to meet patients’ needs for pain management and psychological care. ²⁰ Expanding training of integrated care in family medicine residencies can play a critical role in effectively meeting the increasing need for a workforce to provide such care in response to the surge of opioid overdose deaths. Family physicians are well positioned to address common barriers to caring for patients with HCV and HIV, including social determinants of health, transportation issues, and stigma. Additionally, an integrated care model fits with care for OUD because that care often involves sensitive matters, and most people living with HIV prefer integrated primary and HIV care.^{10, 13}

Previous work found that only 0.53% of ABFM-certified family physicians were certified in addiction medicine, and they were more likely to work in underserved or academic settings. ¹⁶ Those family physicians were more likely to manage comorbid HCV and HIV/AIDS, which is consistent with our study findings. However, given their small numbers, those family physicians alone cannot be relied on to meet societal needs.

Our study had several limitations. First, this study assessed only intended scope of practice, so it may not reflect on actual provision of integrated care. Second, we used county-level data for overdose mortality rate, HCV mortality rate, and HIV prevalence; however, the data may not reflect the patient population residencies serve. Our study findings may not represent the residency characteristics contributing to intended scope of practice covering all three services. Third, our study could show only associations rather than causation given the cross-sectional study design.

In summary, the importance of family physicians’ potential role in providing integrated care of HIV and HCV among people with OUD needs to be highlighted and emphasized by our specialty as a way for family medicine to address a growing societal need. In response to the surging need for this integrated care, policymakers, residency educators, and residency funders/sponsors should increase the workforce of family physicians who can provide this integrated care to meet community needs.

Dr Sonoda received financial support from the American Board of Family Medicine Foundation.

This study was presented at the Society of Teachers of Family Medicine Annual Spring Conference, May 7, 2024, Los Angeles, California.