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Goals and Objectives

The overall goal of the Yale HIV Training Track is to provide Yale primary care residents with the opportunity to enhance their knowledge of HIV disease and associated opportunistic infections, and to provide a venue for them to develop expertise and appropriate professional attitudes regarding a primary care role dealing with HIV infected patients, physician colleagues, ancillary health providers, and administrative staff in a multidisciplinary care model.


This section suggests an outline of the medical knowledge areas, skills, attitudes necessary to reach the overall goal of achieving independent practice status in all 12 EPAs.

Patient Care

Objectives:

Evaluate and manage patients with HIV and other chronic medical problems in an ambulatory and inpatient setting.

A. Evaluate
1. Sexual and substance abuse history/risk factor assessment
2. Comprehensive physical exam
3. Select appropriate diagnostic procedures
4. Interpret HIV testing results
5. Set priorities with patients and families
6. Investigate common symptoms
7. Recognize life-threatening syndromes
8. Know appropriate baseline lab/screening tests

B. Prevent
1. Provide health education and counseling
2. HIV secondary prevention measures - STI screening
3. Prenatal testing/ARVs in pregnancy/breastfeeding

C. Manage
1. Problem list/clinic record
2. Provide ARV
3. Utilize and coordinate consultants
4. Coordinate input and output care
5. Provide competent palliative/end-of-life care
6. Own knowledge base - utilize internet resources for treatment guidelines, self-learning with Cases

D. Procedures
1. HIV testing and counseling
2. Pap smear - cervical and anal
3. Vaginal Wet mount
4. Lumbar puncture

E. Resident as teacher - select, prepare, and teach on HIV preclinic conference topic per year

Medical Knowledge

Objectives:

Review the epidemiology and pathophysiology and be able to recognize and initiate evaluation and management plans for the following disease states/clinical presentations adapted from numerous publicly available sources including DHHS guidelines, IAS, AIDSinfo, HIVInSite (UCSF), AAFP, and others.

Epidemiology

1. Local, regional, global;

2. Disproportionate prevalence in minorities, adolescents, women

Science of HIV

  1. Biology of HIV infection and treatment
    1. Virology/immunopathogenesis of HIV
    2. Immunodeficiency
  2. Clinical Laboratory Testing
    1. Types of tests
      1. HIV antibody assays/confirmatory testing
      2. HIV-1 Viral load Assays
      3. CD4+ lymphocyte count
      4. Resistance testing
        1. Genotypic
        2. Phenotypic
        3. Viral tropism assays
    2. Indications for testing
      1. Risk assessment and voluntary
      2. Universal testing recommendations
      3. Clinical Assessment
        1. Acute retroviral syndrome
        2. Asymptomatic chronic HIV
        3. Symptomatic chronic HIV
        4. AIDS-defining illnesses
    3. Public Health surveillance/reporting
    4. Mandatory testing requirements
    5. Test Results and Counseling
      2. Opt-Out
      3. Pre/post-test counseling
      4. How to give patients results
      5. Partner Notification (CARE program)
      6. Disclosure issues

Diagnosis and Clinical Management

  1. Primary Care
    1. Epidemiology and Disease Progression-Staging (WHO, CDC classifications)
    2. Primary Care
    3. Cardiac Risks in HIV
    4. Symptom Management
    5. Immunizations
    6. Infection and Travel
    7. Nutritional Issues
    8. Women and HIV-reproductive issues/pregnancy
    9. Mental Health and HIV
    10. Substance abuse and HIV
    11. HIV and Aging
  2. Antiretroviral Therapy
    1. Overview of ARVs
    2. When to start/counseling to promote adherence
    3. What to start - DHHS guidelines
    4. Monitoring response/side effects/metabolic complications
    5. Switching due to side effects
    6. Virologic Failure - definition, evaluation, and alternative regimens
    7. Clinical Trials
  3. Systems of Care
    1. Critical Care and HIV
    2. Surgery in HIV
    3. Care of IVDU
    4. Palliative care and HIV
    5. Housing/rehab options with HIV
    6. Legal issues and HIV-disclosure, insurance, OSHA
    7. Health Care financing issues - CMS, Ryan White, CADAP
  4. Clinical Manifestations of HIV
    1. Dermatologic Manifestations
    2. Neurologic Manifestations - HAND, PML
    3. HIV-associated psychiatric disorders
    4. Pulmonary Manifestations
    5. Renal disease in HIV
    6. Cardiac disease in HIV
    7. Endocrine Manifestations in HIV
    8. HIV-associated Wasting
    9. Hematologic manifestations
    10. Gastrointestinal diseases
    11. Ophthalmic manifestations of HIV
    12. Otolaryngolic manifestations of HIV
    13. Rheumatologic and Musculoskeletal Manifestations of HIV
    14. Sexually transmitted infections/li>
  5. Specific Infections associated with HIV
    1. Bacterial infection - sepsis, pneumococcal, mycobacterial (MTB, MAC)
    2. Fungal Infections - pneumocystis, candidates, cryptococcal disease, histoplasmosis, other
    3. Viral Infections - CMV, HSV, VZV , EBV, HCV/HBV, JC, HHV8
    4. Parasitic Infections - cryptosporidiosis
  6. Malignancies associated with HIV
    1. KS/HHV8 - associated
    2. Lymphoma
    3. HPV-related - cervical and anal neoplasia

Transmission

  1. Modes of Transmission
    1. Sexual Vertical: Mother to Child
    2. Intravenous drug use
    3. Prophylaxis - PrEP (microbicides, ARV), circumcision
    4. Prophylaxis - PrEP - occupational/non-occupational
  2. HIV Transmission and Prevention in Specific Populations
    1. IVDU
    2. Adolescents
    3. MSM/other sexual minorities (GLTBQ)
    4. Incorporating HIV prevention

Systems-Based Practice

Objectives:

  1. Acquire and improve skills in accessing information technology to enhance patient care
  2. Apply evidence-based and cost-conscious approaches to care of HIV-infected patient
  3. Describe systems of health care utilized by HIV-patients- (Ryan White, CDC, various public insurers) and demonstrate understanding of how patients can access care within these systems
  4. Understand the process of referral, transfer, and coordination of care within or outside the Network of providers and agencies
  5. Identify areas and develop performance improvement projects using HIV related data in order to enhance the quality of HIV care

Practice-Based Learning

Objectives:

  1. Demonstrate ability to identify and critically evaluate and apply current medical information and evidence-based medicine as it relates to HIV infection and related disorders
  2. Demonstrate system for tracking HIV-associated knowledge and skills to identify personal areas of strength and areas to improve
  3. Use the model for “Ask-Acquire-Appraise-Apply”

Attitudes and Professionalism

Objectives:

  1. Demonstrate sensitivity and responsiveness to patients with respect to ethnic background, religious background, sexual orientation, personal beliefs, etc
  2. Demonstrate respect to colleagues and team by adhering to clinic protocols, completing charts and paperwork in timely manner, participating in clinic initiatives
  3. Demonstrate understanding of and adherence to ethical principles of patient care with attention to privacy and confidentiality.

Interpersonal and Communications Skills

Objectives:

  1. Maintain timely and organized medical notes, including initial clinic notes, follow up notes, and phone notes.
  2. Communicate cross-culturally with patients and families with a broad range of socioeconomic and ethnic backgrounds.
  3. Communicate effectively with physicians and other health care professionals in the context of providing multidisciplinary HIV care.