As Program Director of the Kaiser Permanente Northern California HIV Medicine Fellowship, I am delighted to share our experience in developing and growing a training program aimed at strengthening the HIV clinician workforce. We launched our fellowship in 2020 in response to a critical moment in HIV care: While our workforce was shrinking due to retirement and burnout, the medical needs of people with HIV were becoming increasingly complex, with an aging population.
Brad Hare, MD, Infectious Disease specialist and Chief of HIV Services for Kaiser Permanente Northern California, states: “We are at a critical juncture in the history of HIV. We have the tools to enhance and extend the lives of people with HIV, to prevent HIV in people at risk, and to end the HIV epidemic. The critical component needed to make this a reality are well-trained medical providers who understand the complex interaction between the science and the individual and between public policy and community health.”
We designed our fellowship to equip internal medicine and family medicine physicians with the skills necessary to care for this evolving and dynamic patient population. The fellowship curriculum combines a strong foundation in HIV primary care with focused training, in gender-affirming care, addiction medicine, HIV prevention, dermatology, sexual health and anal cancer screening. Fellows gain hands-on experience delivering high-quality, evidence-based HIV care across a variety of clinical settings.
Community Partnerships Enrich the Fellowship
A key strength of our program is our collaboration with a diverse network of community partners that provide fellows with rich, immersive clinical experiences across the full spectrum of HIV care. These include the inpatient HIV service at Zuckerberg San Francisco General Hospital, where fellows care for patients with advanced HIV and complex opportunistic infections. There, the fellows gain hands-on experience in diagnostic reasoning, multidisciplinary management, and the care of vulnerable populations. Through partnerships with San Francisco Community Health Center, fellows engage in street medicine and low-barrier care models, which helps them to develop skills in outreach, harm reduction, and longitudinal engagement with individuals experiencing homelessness and substance use disorders.
Our collaboration with the National Clinician Consultation Center offers fellows access to nationally recognized expertise in HIV, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and substance use management, fostering a deeper understanding of evidence-based decision-making and the ability to navigate complex clinical scenarios through consultation. Additionally, at San Francisco’s City Clinic, fellows gain exposure to high-volume sexual health services, including STI screening and treatment, HIV prevention, and public health approaches to sexual health care.
Through these partnerships, fellows develop a nuanced understanding of diverse models of HIV care delivery—ranging from academic inpatient services to community-based and public health settings—and how to adapt care to meet the needs of different patient populations. Importantly, these experiences highlight the structural and social determinants that shape HIV outcomes, while equipping fellows with the skills to deliver compassionate, equitable, and context-responsive care across health care systems and community contexts.
Fellowship Graduates Support Their Communities
To date, we have graduated six cohorts of fellows who have gone on to practice in a wide range of practice settings including the public health department, correctional health systems, academic medical centers, federally qualified health centers, and our own integrated health care system. It has been incredibly rewarding to see our graduates apply their training in meaningful ways within the communities they serve.
Leah Goodman, MD, one of our inaugural fellows and now Associate Program Director of the fellowship, reflects on her decision to pursue additional training: “I wanted to build a strong foundation grounded in both the primary research and direct experience managing antiretroviral therapy, and to build up my network of colleagues to turn to for guidance. I was also drawn to the opportunity to explore areas such as HIV dermatology and anal dysplasia, topics that were difficult to fully engage with during residency.”
This sentiment is echoed by another of our graduated fellows, Avani Dalal, MD, an HIV specialist at Jefferson Einstein Philadelphia Hospital. “This fellowship changed the trajectory of my career. During fellowship, I gained confidence as a physician, acquired so much knowledge, had the opportunity to continue my love of teaching, find a new interest in research, and discover my passion for women’s health and perinatal HIV care. I truly love what I do and it’s made possible due to my time with the fellowship.”
Their perspectives reflect a broader theme among our fellows: a desire to deepen their expertise within a primary care framework while gaining exposure to specialized areas of HIV medicine. Many graduates have gone on to develop focused clinical interests including anal cancer screening with training in high-resolution anoscopy and perinatal HIV care.
Responding to Declining Interest in HIV Medicine
At the same time, our fellowship has mirrored broader challenges within the field. There appears to be declining interest in HIV medicine, paralleling trends seen in infectious diseases and other non-procedural specialties. Multiple factors likely contribute to this, including limited awareness of HIV medicine as a career pathway among trainees, concerns about additional years of training, and the financial pressures facing residents as they complete their education.[i]
Telchik et al., in their study examining declining interest in infectious diseases fellowship training, identified lower compensation, long working hours, and a lack of procedural opportunities as key deterrents.[ii] In my other role as faculty within an internal medicine residency program, I have similarly observed that many medical students and residents are not exposed to HIV medicine as a distinct and rewarding career option and have had limited exposure to dedicated infectious disease training opportunities early on in their medical education.
In response, we have prioritized early engagement and outreach to trainees at all levels. Evidence suggests that exposure to infectious disease-related educational experiences early in medical education is strongly associated with future interest in the field.[iii] Derek Blechinger MD, MPH, is an HIV specialist and directly involved in many of our educational opportunities focused on HIV and LGBTQ+ care. He says, “Building the pipeline is essential and we’ve intentionally created experiences at multiple levels. From early medical school programming, PrEP Bootcamp and LGBTQ+ Health at Kaiser Permanente[iv], to medical student clerkships through AAMC Visiting Student Learning Opportunity[v] program, learners are introduced to both the curriculum and the joy of sexual health work.
This continues through our LGBTQ+ primary care track for Internal Medicine residents, ID/HIV elective rotations, and visiting resident electives in HIV/LGBTQ+ care. We’ve created a comprehensive and dynamic educational pipeline for our learners.” Our fellows are actively involved in our educational programming as well, including delivering lectures at local internal medicine and family medicine residency programs and presentations at regional conferences.
Additional Factors Influencing HIV Careers
Additional external factors—including increasing anti-LGBTQ+ legislation[vi], instability in research funding, and broader uncertainty within health care—may also influence career choice. HIV medicine sits at the intersection of many of these challenges, further complicating efforts to recruit and retain a robust workforce.
I also can’t overemphasize the role of mentorship in career choice and evolution. Our fellowship benefits from numerous faculty from varied disciplines who donate their time, expertise, and mentorship. Multiple studies have shown a link to mentorship and the ultimate career choices of our learners.[vii] O’Rourke et al found in their survey of primary care Internal Medicine residents, that mentorship along with residency clinical experiences and breadth of experiences led to IM residents choosing a primary care career path.[viii] Supporting our faculty with career development, mentorship, and time is imperative in demonstrating how rewarding a career in HIV medicine can be to our learners.
Sarah Baranes, MD, one of our current HIV fellows, highlights the importance of mentorship in her HIV fellowship training: “Being able to talk through each patient’s care with HIV specialized primary care preceptors created a precedent for thoughtful and collaborative care. These same clinicians became mentors who helped me tailor the curriculum to my specific interests, preparing me for the next step.”
Hope for the Future of HIV Medicine
Reflecting on the growth of our fellowship, I am deeply proud of the fellows we have trained and the faculty who have contributed their expertise, mentorship, and passion to this work. HIV medicine is a field that demands resilience, adaptability, and dedication while being profoundly meaningful.
While the future of our field is not without uncertainty, the commitment and enthusiasm I have seen from the next generation of clinicians give me great hope—for both our patients and for the continued advancement of HIV care.
