Abstract
The United States continues to face a mismatch between demand for HIV prevention and care and the supply of clinicians prepared to deliver those services. At year-end 2024, more than 1.1 million people had diagnosed HIV in the United States, and nearly 39,000 people received an HIV diagnosis that year.1 This workforce shortage is not only a staffing concern; it threatens equitable access to pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), antiretroviral therapy (ART), retention in care, and viral suppression. Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), along with pharmacists, should be recognized as essential members of an interprofessional HIV workforce capable of extending services into primary care, pharmacies, safety-net settings, and underserved communities.
This narrative review and practice-informed analysis examines workforce gaps, scope-of-practice and reimbursement barriers, educational needs, and implementation strategies for integrating APPs and pharmacists into HIV prevention and treatment. Recent national evidence indicates that most measured HIV outcomes are comparable across provider types, while pharmacist interventions can improve adherence and virologic outcomes (Ahmed et al., 2022; Weiser et al., 2024).2,3 Achieving national HIV goals will require coordinated action by policymakers, payers, academic programs, health systems, and professional organizations to remove barriers, prepare the workforce, and scale team-based care models.
Introduction
The HIV epidemic in the United States remains a significant public health challenge, and workforce capacity is central to the country’s ability to respond. At year-end 2024, more than 1.1 million people had diagnosed HIV, and 38,793 people received an HIV diagnosis during the year.1 Despite major advances in ART, PrEP, PEP, and long-acting prevention strategies, gaps in linkage, retention, PrEP uptake, and viral suppression persist.4
A major contributor to these gaps is the limited supply and uneven distribution of HIV-trained clinicians. Workforce capacity is threatened by anticipated retirements, geographic concentration of expertise, administrative burden, and difficulty recruiting clinicians into HIV practice.5,6 Addressing these pressures requires moving beyond physician-centric models toward interprofessional HIV care teams that fully integrate APPs and pharmacists as core contributors to prevention, treatment, medication access, adherence support, and long-term care delivery.
This article uses a narrative review and practice-informed analysis to synthesize current evidence, workforce reports, policy examples, and implementation considerations related to HIV care delivery by APPs and pharmacists in the United States. It argues that APP and pharmacist integration must become a core HIV workforce strategy and that progress depends on aligned action across scope-of-practice policy, reimbursement, education, and team-based implementation. The central question is no longer whether APPs and pharmacists can help close HIV care gaps, but whether health care systems and policymakers will remove the barriers that keep this workforce underused.
In summary, the article argues that closing HIV workforce gaps requires a sequenced strategy: first, remove policy and reimbursement barriers that constrain APP and pharmacist practice; second, strengthen HIV-focused education, mentorship, and experiential training; and third, scale team-based delivery models that extend prevention and treatment services into the settings where access gaps are greatest.
The Expanding Role of Advanced Practice Providers in HIV Care
APPs, including NPs and PAs, can expand HIV care capacity in primary care, safety-net, and underserved settings. National evidence shows that most measured HIV outcomes do not differ meaningfully by provider type, and patients cared for by NPs had higher adjusted retention and sexually transmitted infection testing than patients cared for only by infectious disease physicians.3 With HIV training, access to consultation, and defined referral pathways, APPs can increase appointment availability, strengthen continuity, and distribute HIV care responsibilities across a broader team.
Key APP contributions include:
- Initiating and managing ART.
- Prescribing PrEP and PEP.
- Managing comorbid conditions and routine follow-up.
- Delivering patient-centered, culturally responsive care.
Because many primary care clinicians report limited preparation for HIV care, APP integration should be paired with practice-based education, consultation pathways, and ongoing support.7
The Critical Role of Pharmacists in HIV Prevention and Treatment
Pharmacists are essential to HIV prevention and treatment because many access barriers are medication-related. They support ART and PrEP continuity by identifying drug-drug interactions, counseling on adherence, managing refills, assisting with insurance and prior authorizations, and helping patients navigate medication access. A systematic review and meta-analysis found that pharmacist care improved adherence and virologic outcomes among people with HIV.2
Key pharmacist contributions include:
- Optimizing ART and managing drug-drug interactions.
- Supporting PrEP and PEP access where permitted.
- Providing adherence counseling and education.
- Navigating insurance, prior authorizations, and 340B
However, inconsistent state scope-of-practice laws and regulatory restrictions continue to limit pharmacist integration into HIV care delivery.
Barriers to HIV Workforce Expansion
Educational Gaps
Educational gaps constrain workforce expansion when NP, PA, and pharmacy graduates enter practice without applied experience in HIV screening, PrEP, PEP, ART fundamentals, stigma reduction, and longitudinal care. Programs should move beyond isolated lectures by using case-based instruction, supervised clinical exposure, and interprofessional training that prepares clinicians to integrate HIV services into routine care.7
Scope-of-Practice and Regulatory Barriers
State-specific rules create uneven access to HIV services. Supervision or collaboration requirements may limit NP practice in shortage areas, while pharmacist authority to initiate or dispense PrEP and PEP varies widely. Georgia’s statewide PEP standing order shows how targeted policy change can expand timely access while preserving referral and follow-up requirements.8
Reimbursement and Financial Constraints
Inadequate reimbursement for PrEP counseling, care coordination, adherence support, and medication-access work undermines workforce sustainability. Many clinics rely on Medicaid, safety-net funding, and the Ryan White HIV/AIDS Program that serves as the payer of last resort for eligible services.9 When payment does not reflect the complexity of HIV prevention and treatment, reimbursement becomes a workforce barrier as well as a financing issue.
Administrative Burden and Burnout
Documentation demands, prior authorizations, denials, pharmacy restrictions, and medication-assistance requirements contribute to burnout and delay time-sensitive care.6 These burdens are especially consequential for PEP initiation and uninterrupted access to ART or long-acting prevention and treatment.10
Stigma and Communication Barriers
HIV-related stigma and discomfort with sexual health discussions reduce screening and prevention opportunities. Standardized sexual-history tools, stigma-reduction training, and team-based workflows can make these conversations routine and reduce missed opportunities.
Clinical Practice Gaps
National data and clinician-readiness research identify persistent gaps across the HIV care continuum:4,7
- Incomplete uptake of PrEP among people who could benefit.
- Missed opportunities for routine HIV screening.
- Delayed diagnosis and linkage to care.
- Limited adoption of emerging prevention strategies, such as Doxy-PEP.
These gaps show why workforce expansion must address prevention, diagnosis, treatment, and long-term engagement across primary care, pharmacy, safety-net, and specialty settings.
Discussion
The evidence summarized in this article indicates that HIV workforce expansion should be understood as both a clinical access strategy and a health equity strategy. APPs and pharmacists bring complementary capabilities that can reduce bottlenecks in prevention, medication access, adherence support, chronic disease management, and care coordination. However, their impact depends on whether health systems, payers, academic programs, and policymakers create the conditions for sustainable integration rather than relying on individual clinician initiative. The central implication is that HIV workforce reform must move beyond simply increasing the number of clinicians and toward redesigning care teams so HIV expertise is distributed across the settings where patients already seek care.
Prioritized Recommendations to Strengthen the HIV Workforce
Priority 1: Remove policy and payment barriers
The first priority is to remove structural barriers that prevent APPs and pharmacists from practicing at the top of their education and licensure. State policy should expand appropriate scope-of-practice authority, including pharmacist access to time-sensitive services such as PEP, while payers should reimburse PrEP counseling, adherence support, care coordination, medication-access work, and follow-up services. Georgia’s pharmacist PEP standing order illustrates how targeted policy change can create timely access points while preserving referral and follow-up requirements.8
Priority 2: Build the HIV workforce pipeline
Once enabling policies and reimbursement conditions are addressed, academic and clinical training systems should prepare APPs and pharmacists to confidently deliver HIV prevention and care. NP, PA, and pharmacy curricula should include core HIV competencies, case-based learning, stigma-reduction training, supervised clinical rotations, mentorship, and interprofessional learning experiences. The National AETC Support Center connects clinicians with regional preceptorships and other experiential training opportunities; expanding these pathways nationally would help translate training into practice readiness.11
Priority 3: Scale team-based delivery models
Health systems should then scale interprofessional delivery models that extend HIV expertise into primary care, pharmacy, safety-net, rural, and underserved settings. Telehealth can support remote consultation, follow-up, adherence counseling, and shared management with local teams, but its value is greatest when connected to laboratory testing, medication access, injections, and referral services.12 Long-acting prevention options can further expand capacity when systems invest in workforce training, injection competency, prior-authorization support, recall systems, and protocols for missed doses.13
Several limitations should be acknowledged. Workforce integration can expand HIV service capacity, but it cannot by itself resolve structural drivers of inequity such as poverty, insurance instability, transportation barriers, stigma, housing insecurity, and uneven public health infrastructure. In addition, scope-of-practice laws, reimbursement rules, and pharmacist authority vary by state, so successful models will require local adaptation rather than direct replication.
Future Directions
Future directions should shift from workforce expansion as an aspiration to workforce integration as an accountable implementation strategy. Academic programs, payers, policymakers, health systems, professional organizations, and community partners should align training, scope-of-practice authority, reimbursement, mentorship, and implementation support to enable APPs and pharmacists to deliver HIV prevention and care sustainably. Future research should evaluate which team-based models most effectively improve PrEP uptake, PEP access, retention in care, viral suppression, workforce diversity, patient experience, and access in underserved communities.
Conclusion
The HIV workforce shortage is not only a staffing challenge; it is a direct threat to equitable access, timely prevention, sustained treatment, and national HIV outcome goals. NPs, PAs, and pharmacists should be recognized not as substitutes for physicians, but as essential members of an interprofessional workforce with complementary expertise and the capacity to extend HIV services into primary care, pharmacies, safety-net settings, and underserved communities.
The path forward requires coordinated action: policymakers should remove unnecessary scope-of-practice barriers; payers should reimburse for prevention, care coordination, adherence, and medication access work; academic programs should prepare graduates for HIV prevention and care; and health systems should implement team-based models that make those roles sustainable.
Without these aligned reforms, the United States will continue to underuse a capable workforce while preventable gaps in PrEP uptake, PEP access, viral suppression, retention in care, and equitable service reach persist. The call to action is clear: Expanding and fully integrating APPs and pharmacists must become a core HIV workforce strategy, not an optional supplement to existing care models.
