HIV Care for Adolescents and Young Adults: Comparing Nurse Practitioner and Physician Care in Engagement, Trust, and Clinical Outcomes

TL;DR

Nurse practitioners can provide HIV care for young adults with results as good as physicians, and may improve trust and engagement.

Contribution

Demonstrates that NP-led HIV care for youth achieves comparable clinical outcomes and higher trust than physician-led care.

Findings

Viral suppression was similar between NP-led and physician-led care.

Youth with NP-led care had higher CD4 counts, more visits, and greater telehealth use.

Patients reported higher trust in nurse practitioners compared to physicians.

Abstract

Shortages in the HIV workforce threaten equitable access to care for youth with HIV (YWH) experiencing high rates of undiagnosed infection and suboptimal engagement. Nurse practitioners (NPs) may expand HIV care capacity, but evidence is limited.

We conducted a cross-sectional study in two U.S. adolescent and adult HIV programs. Electronic health record data were merged with patient-reported surveys assessing trust, adherence, and stigma across an eight-month pre– and post–COVID-19 period. Provider type’s (NP vs. physician) were compared.

Among 109 participants (mean age 26 years), viral suppression did not differ by provider type. Youth receiving NP-led care had higher CD4 counts, more visits, greater telehealth use, and were more likely to report higher patient-provider trust.

NP-led HIV care for youth achieved clinical outcomes comparable to physician care and was associated with higher trust and engagement, underscoring the role of nurse practitioners in strengthening the HIV workforce.

Full text

Introduction

A shortage in the U.S. HIV clinical provider workforce limits equitable access to HIV prevention and treatment services, particularly for adolescents and young adults aged 13–34, who account for 58% of HIV infections nationwide (Armstrong, 2020; Bono et al., 2021; Centers for Disease Control and Prevention, 2023; Kelly et al., 2024). Predicted more than a decade ago, this shortage reflects the retirement of early HIV specialists, limited growth in infectious diseases training programs, and insufficient HIV-focused pathways in primary care residencies (Budak et al., 2021; Gilman et al., 2016; Gilman B., 2013; Stevens et al., 2008; Weiser et al., 2016; Weiser et al., 2019). Despite efforts to expand training, infectious disease fellowship enrollment declined by 8.1% between 2008 and 2022, and more than half of fellowship programs did not fill available positions in 2024 (Kelly et al., 2024). In 2024, 51% of fellowship programs did not fill available spots for infectious diseases fellows. Further, dedicated HIV training pathways built into family medicine residency programs generated only 38% of physicians providing HIV health services (Budak et al., 2021). Compounding these challenges, few HIV-trained clinicians practice in southern or rural regions, which now represent the epicenter of the U.S. HIV epidemic (Centers for Disease Control and Prevention, 2023; Schafer et al., 2017).

National workforce projections further underscore these inequities. Health Resources and Services Administration analyses estimate that the rural infectious disease workforce will meet only 14% of projected demand between 2024 and 2036 (Department of Health and Human Services, 2024). Similarly, the adolescent medicine workforce, another critical pipeline for youth HIV prevention and treatment, is projected to decline and remains unevenly distributed geographically (Fields et al., 2024). Insurance access further constrains care delivery, as an estimated 25% of family physicians and 15% of pediatric primary care physicians caring for youth with HIV no longer accept Medicaid, the primary payer for people living with HIV (Kates et al., 2021). Together, these factors create persistent barriers to youth-focused HIV prevention and treatment and threaten progress toward the Ending the HIV Epidemic initiative, which aims to reduce new HIV infections in the United States by 2030 (Armstrong, 2020; HHS, 2022).

These workforce gaps are particularly concerning given that youth aged 13–24 have the highest proportion of undiagnosed HIV infections at 44%, substantially exceeding other age groups (Centers for Disease Control and Prevention., 2021). HIV testing rates in this population remain low, with fewer than one in four youth reporting having been tested (Mustanski et al., 2020; Zapata et al., 2024). Evidence indicates that youth are significantly more likely to undergo HIV testing when they have clinicians with whom they can discuss sexual health and HIV openly, underscoring the importance of accessible, developmentally responsive care (Mustanski et al., 2020; Zapata et al., 2024). Ensuring a workforce capable of engaging youth in these conversations is therefore central to HIV prevention and early treatment efforts.

Nurse practitioners represent a rapidly expanding segment of the U.S. healthcare workforce and are well positioned to address these gaps (Bureau of Labor Statistics, 2023; K., 2023). As nationally board-certified advanced practice nurses, NPs receive graduate-level training in advanced assessment, pharmacology, and population-focused care, with an emphasis on addressing social, behavioral, and structural determinants of health Federal investments in HIV-focused NP training programs, including those supported by HRSA, have further strengthened this workforce (Farley et al., 2016). Prior studies demonstrate that HIV care delivered by NPs achieves clinical outcomes comparable to physician-led care, with some evidence of advantages in prevention counseling, adherence support, and retention (Wilson et al., 2005; Zhang et al., 2020; Weiser et al., 2024). However, evidence specific to adolescents and young adults with HIV remains limited, despite their disproportionate burden of disease and elevated risk of disengagement from care (Mgbako et al., 2022). Relational aspects of care, including trust, may be especially salient for sustaining engagement in this population.

This study was conceptually informed by the Trust-Link Relational Transition Model (Blinded, 2025), which frames trust as a relational process that shapes engagement, continuity, and health outcomes for youth with chronic illness. The model integrates nursing and trust theory to emphasize informed trust, relational presence, and collaborative care as mechanisms that support youth engagement during vulnerable care transitions. Given evidence that trust mediates retention and adherence in HIV care, particularly among youth facing stigma and developmental transitions, this framework guided our selection of patient-reported trust measures and our hypothesis that NP-led HIV care would demonstrate relational strengths alongside equivalent clinical outcomes.

Prior studies comparing nurse practitioner and physician HIV care demonstrate comparable quality across key clinical outcomes, including antiretroviral therapy initiation and prescribing, immune markers, viral suppression, and sexually transmitted infection testing (Wilson et al., 2005; Zhang et al., 2020). More recent findings further support the role of nurse practitioners in high-quality HIV care. An analysis of the Centers for Disease Control and Prevention’s Medical Monitoring Project (2019–2021) involving 6,323 adults, found that individuals whose primary HIV care providers were NPs had significantly higher rates of retention in care and were more likely to receive HIV testing recommendations than those with infectious disease (ID) physician providers (Weiser et al., 2024). In addition, among young adults, nurse practitioners provided a greater number of HIV prevention and treatment services per patient than both infectious disease and non–infectious disease physicians, including routine HIV care, STI testing, and adherence counseling (Weiser et al., 2024; Zhang et al., 2020). Despite this growing evidence base, data specific to adolescents and young adults with HIV remain limited (Mgbako et al., 2022). Accordingly, the aim of this study was to compare HIV-specific clinical outcomes and patient-reported outcomes among youth with HIV receiving care from nurse practitioners versus physician providers.

Methods

This cross-sectional observational study examined clinical characteristics and health outcomes among YWH based on their primary provider type (nurse practitioner [NP] versus physician). Data were abstracted from electronic medical records and included demographics, HIV-specific outcomes, visit types, and engagement in care (EIC). The HIV-specific outcomes of interest were HIV RNA PCR (copies/μL), CD4 absolute cell counts, and CD4 percentage. For each participant, HIV viral suppression was assessed using their HIV RNA PCR test results across the 16-month study period. Participants were classified as “suppressed” if all HIV RNA PCR results during that period were < 200 copies/μL. This binary outcome was used to compare viral suppression across provider types.

Visit types were categorized as in-person, telehealth (video or phone), or hybrid. Engagement in care (EIC) was operationalized as a binary variable. Participants were classified as “engaged in care” using a modified definition based on Ryan White HIV/AIDS Program retention measures and CDC Medical Monitoring Project criteria. Because data were pulled 8 months after the onset of the COVID-19 pandemic (March 15, 2020), the 16-month study period included the 8 months before and after that date. Participants were considered engaged if they had at least one HIV care visit in both time periods, had at least one HIV RNA PCR test during the study window, and demonstrated sustained viral suppression (defined as all HIV RNA PCR results < 200 copies/μL) (Dasgupta et al., 2021; HRSA, 2019). Those not meeting these criteria were classified as “not engaged in care.”

Patient-reported outcomes were collected using a self-administered survey and included measures of patient-provider trust, ART adherence, and HIV stigma. Trust was assessed using three validated tools: the Healthcare Relationship Trust Scale-Revised (HCR Trust Scale-R) (Bova et al., 2012), the Watson Patient Caring Score (WPCS) (Brewer & Watson, 2015), and the Patient Trust Assessment Tool (PaTAT) (Velsen et al., 2017). The HCR Trust Scale-R is a 13-item scale measuring perceived provider trust using a 5-point Likert scale, with strong internal consistency (Cronbach’s α > .91) and moderate test-retest reliability (r = .59) (Bova et al., 2012). The WPCS is a 5-item measure of human caring practices using a 7-point scale (Cronbach’s α = .90) (Brewer & Watson, 2015). The PaTAT consists of 25 items that evaluate trust in electronically delivered health services (Van Velsen et al., 2016; Velsen et al., 2017).

Adherence to ART was measured using a validated self-report scale widely used in HIV care (Wilson et al., 2020). HIV stigma was assessed using the revised 12-item HIV Stigma Scale, which uses a 4-point Likert scale and has demonstrated acceptable internal consistency (Cronbach’s α > .70) (Reinius et al., 2017). Data collection spanned from June 2019 to November 2020 and was designed to capture eight months before and after the onset of the COVID-19 pandemic, operationalized as March 15, 2020, when emergency public health orders were enacted in Colorado. Participants were purposively sampled from two affiliated ambulatory HIV clinics located within a quaternary children’s hospital and its university-based adult counterpart. Eligible participants were 18 to 30 years old, living with perinatally or situationally acquired HIV, English-speaking, and receiving or previously received care at one of the two sites. Although the study targeted this age range, a small number of individuals (n = 7) over age 30 with perinatally acquired HIV were included due to their participation in a long-term observational study and to capture insights related to their transition to adult HIV care. We excluded pregnant individuals due to the increased frequency of visits associated with perinatal care standards. Recruitment occurred via text, phone, email, and secure messaging through the electronic health record. Surveys were administered via REDCap (Harris et al., 2009) at the University of Colorado following electronic informed consent. The Colorado Multiple Institutional Review Board (COMIRB #20–2536) approved the study. Data analysis included chi-square, Fisher’s exact, and Wilcoxon rank sum tests, conducted using SPSS software (IBM, 2020).

Results

Of the 281 youth with HIV (YWH) who were screened and approached for participation, 109 individuals (38.8%) provided informed consent, completed the electronic survey, and were included in the final sample for the chart abstraction. The average age of participants was 26.4 years (SD = 4.04); 60.6% identified as male, 1.8% as transgender female, and 0.9% as transgender male. Regarding race and ethnicity, 48.7% identified as Black, American Indian, or mixed race, and 73.4% identified as non-Hispanic or Latino. A total of 43 participants (39.4%) had perinatally acquired HIV. Seventy participants (64.2%) identified their primary HIV provider as a physician, while 38 (34.9%) received care from a nurse practitioner; one participant had missing provider information and was excluded from provider-level comparisons (Table 1).

Participant characteristics-including race, ethnicity, gender, and mode of HIV acquisition-did not differ significantly by provider type (Table 2). There were no significant differences in HIV viral load (p = 0.907; mean difference [95% CI]: 0.07 [–0.07, 0.22]) or engagement in care-defined as having at least one pre- and post-COVID visit, one HIV RNA PCR test, and all PCRs < 200 copies/μL-between provider types (49.0% among participants with physician providers vs. 44.0% among those with nurse practitioner providers; p = 0.703; φ = 0.017; Table 3) over the full 16-month study period (June 2019–November 2020). Participants who received care from nurse practitioners also had significantly higher mean CD4 absolute counts and CD4 percentages compared to those with physician providers (Table 4). The mean CD4 absolute count was 765.0 cells/μL for NP patients and 613.0 cells/μL for physician patients (p = 0.043; Cohen’s d = 0.451). The mean CD4 percentage was 35.5% among NP patients and 30.8% among physician patients (p = 0.039; Cohen’s d = 0.460), reflecting small to moderate effect sizes.

Notably participants who received care from a nurse practitioner had a higher mean number of total HIV care visits during that period (mean = 4.0) than those who received care from a physician (mean = 3.0; p = 0.019; Cohen’s d = 0.455) (Table 3). Overall, 59.0% of participants received their HIV care in person. In-person visits were more frequent among those with physician providers (78.0%) than those with nurse practitioner providers (22.0%; p = 0.010). Conversely, participants with nurse practitioner providers had significantly more telehealth visits (55.0%) than those with physician providers (45.0%; p = 0.002) (Table 2).

Among patient-reported outcomes, 23.0% of all participants scored in the high range on the patient-provider trust scale, defined as a total score of ≥ 49 (Bova et al., 2012) (Table 4). A greater proportion of nurse practitioner–treated participants achieved high trust scores (≥ 49) compared to those treated by physicians (65.8% vs. 42.9%; p = 0.038; φ = 0.200). Middle-range trust scores (40–48) were reported by 32.4% of participants, while low trust (< 40) was less common and did not differ significantly between groups (15.8% vs. 17.1%; p = 1.000; φ = 0.000) (Table 4). No significant differences were found in continuous trust scores across the HCR Trust Scale, Watson Patient Caring Score (WPCS), or Patient Trust Assessment Tool (PaTAT), supporting the overall pattern of greater high-trust ratings among NP-managed youth without mean differences across full trust scales (Table 4).

No significant differences were observed in medication adherence (73.0% for nurse practitioner patients vs. 87.0% for physician patients; p = 0.154), depressive symptoms (PHQ-4 ≥ 6: 63.2% vs. 62.9%; p = 1.000), psychological distress (K6 ≥ 5: 36.8% vs. 31.4%; p = 0.722), or HIV stigma (mean difference [95% CI]: 0.02 [–0.23, 0.28]; p = 0.855) between provider groups. (Table 4).

Discussion

The results of this study suggest that nurse practitioners (NPs) and physicians provide comparable HIV care to youth across several critical clinical outcomes, including HIV viral load suppression, engagement in care, medication adherence, and HIV stigma. Demonstrating equivalency in these areas is an important contribution, especially in the context of a growing HIV provider shortage and geographic disparities in access to care (Armstrong, 2020; Bono et al., 2021; Department of Health and Human Services, 2024).

Ensuring that NPs provide care that meets the same clinical benchmarks as physicians supports their broader integration into the HIV workforce and offers a sustainable strategy for scaling youth-focused HIV services. At the same time, NPs demonstrated modest but meaningful advantages in specific domains. Participants cared for by NPs had significantly more visits, greater engagement in telehealth, and reported higher levels of trust in their providers. The difference in telehealth engagement, supported by a small-to-moderate effect size (φ = 0.245), underscores the potential for NP-led models to improve care flexibility and access for youth living with HIV. In addition, participants in NP care had higher CD4 absolute counts and CD4 percentages, with small-to-moderate effect sizes. While these immune function differences are multifactorial, they may reflect greater continuity, accessibility, or relational engagement in NP-managed care. This may also be related to sicker patients being assigned to physicians when they enter HIV care, however that was not a standard practice at either of these HIV clinical programs. These findings suggest that in some cases, NP care may not only be equivalent but beneficial across dimensions of access, immune health, and trust.

Trust emerged as a particularly important differentiator in this study and aligns with the Trust-Link Relational Transition Model (Blinded, 2025), which conceptualizes trust as a relational process that supports continuity and engagement in care. Youth receiving NP care were significantly more likely to report high levels of trust (≥ 49 on the HCR Trust Scale-R), while low trust scores were relatively uncommon and did not differ significantly between groups. The majority of remaining participants fell into a middle trust range (40–48), reported by 32.4% of the sample (Table 4). Prior research shows that trust mediates the relationship between health literacy and both retention and medication adherence in HIV care (Mgbako et al., 2022). Notably, every five-point increase on a 60-point trust scale is associated with a nearly 25% increase in care retention (Graham et al., 2015). Trust has also been described by patients as integral in quality care, particularly in people with HIV who may experience stigma and marginalization (Mgbako et al., 2022).

Consistent with the Trust-Link model’s emphasis on informed trust and reciprocal collaboration, higher trust among NP-managed youth may reflect relational practices that promote engagement and continuity rather than discipline-specific differences in clinical competence. These findings address an important evidence gap regarding the quality and characteristics of HIV care delivered by NPs to adolescents and young adults. Rather than being positioned merely as substitutes for physicians, NPs may offer unique strengths-including enhanced trust, flexibility in care delivery, and immune health outcomes-that support their value in HIV workforce planning. Future studies should build on these findings across larger, multi-site samples to further explore how NP-led care may promote health equity and continuity among youth with HIV, especially in underserved or high-need settings.

Implications for Practice

Expanding HIV Services Through NP Workforce

Given the high proportion of undiagnosed HIV and low testing rates among young people, findings from this study support targeted investment in a nurse practitioner (NP) HIV workforce focused on youth to expand access to testing, treatment, and linkage to care, including through the Ryan White HIV/AIDS Program (RWHAP). Although RWHAP serves more than 500,000 individuals nationally, only one in five patients is a youth with HIV, with similarly low representation across rural and non-rural settings (Klein et al., 2020). Notably, the percentage was roughly equal for rural (20.0%) and non-rural (22.0%) RWHAP providers (Klein et al., 2020). Limited access to youth-focused HIV testing and linkage, particularly in rural and southern regions, has been identified as a contributor to persistent geographic disparities in HIV incidence (Klein et al., 2020). Expanding NP-led HIV services for young people aligns with evidence supporting community- and school-based HIV prevention approaches and may strengthen linkage to care in underserved settings (Mavedzenge et al., 2014).

School-Based Health Centers as a Strategic Platform

School-based health centers (SBHCs) represent a promising platform for NP-led HIV prevention and linkage to care. A recent CDC initiative implemented across 28 school districts reached approximately two million students and demonstrated the feasibility of integrating HIV testing and referral within school settings (Wilkins et al., 2022). Nationally, NPs provide the majority of preventive services in SBHCs, positioning them as key providers for youth-focused HIV care (Soleimanpuor S., 2023). Evidence from SBHC settings shows improved uptake of STI testing and other preventive services when interventions are delivered by NPs rather than computer-based models (Sharma et al., 2022), as well as benefits across reproductive and mental health outcomes (Arenson et al., 2019). Given the higher trust and telehealth engagement observed among youth receiving NP care in this study, integrating NP-led relational and telehealth approaches within SBHCs may enhance HIV testing, referral, and continuity of care.

Community-Based NP Services for Youth with HIV

Beyond school settings, expanding community-based NP HIV services for youth may further improve prevention and engagement. Prior evidence indicates that NPs are more likely than physicians to deliver key HIV prevention services, including pre-exposure prophylaxis prescribing (Zhang et al., 2020). Systematic reviews of HIV care delivery models suggest comparable clinical outcomes across provider types, with advanced practice models offering a feasible approach for comprehensive HIV care delivery (Kimmel et al., 2016). Together with the current findings, this evidence supports the expansion of community-based NP HIV services as a strategy to improve access, trust, and continuity of care for youth with HIV.

Limitations and Strengths

This study has several limitations. The sample size was relatively small and drawn from a single institution, which may limit generalizability. However, these findings provide a valuable foundation for future multi-site studies to further investigate differences in HIV care delivery models. Additionally, CD4 values were analyzed post hoc and not part of the original statistical plan, warranting cautious interpretation. Despite these limitations, this study has notable strengths. We assessed multiple patient-reported outcomes using validated instruments, including trust, adherence, and stigma-domains that are often underexplored in HIV care for adolescents and young adults (Mgbako et al., 2022; Reinius et al., 2017). Our evaluation of these psychosocial and engagement-related factors in YWH, a population often underrepresented in the literature, provides a unique contribution. Furthermore, our use of patient-reported outcome measures supports the advancement of patient-centered HIV care that includes shared decision-making and individualized care planning (Carfora et al., 2022). These elements of care delivery are especially critical to meet the developmental and relational needs of youth living with HIV (Opel, 2018).

Conclusion

This study provides evidence that nurse practitioners deliver HIV care to adolescents and young adults that is comparable to physician care across key clinical outcomes, with additional strengths in trust, visit frequency, and telehealth engagement. These findings support the role of nurse practitioners as a critical component of a youth-focused HIV workforce at a time of persistent provider shortages and inequities in access to care. Higher trust among youth receiving NP care highlights the importance of relational approaches in sustaining engagement during a vulnerable developmental period. Expanding NP-led HIV care models may represent a feasible and effective strategy to enhance access, continuity, and patient-centered care for youth living with HIV. Future multi-site studies are warranted to further examine how NP-delivered care can be leveraged to advance equity and engagement across diverse HIV care settings.

Supplementary Material

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