##M

Medfash.org.uk


HIV in Primary Care An essential guide for GPs, practice nurses and other members of the primary healthcare team by Dr Sara Madge, Dr Philippa Matthews, Dr Surinder Singh and Dr Nick Theobald a charity supported by the British Medical Association by Dr Sara Madge, Dr Philippa Matthews, Dr Surinder Singh and Dr Nick Theobald Medical Foundation for AIDS & Sexual Health (MedFASH)* * registered charity no: 296689 HIV In PrImary Care 2nd edition Published by:
Medical Foundation for AIDS & Sexual Health (MedFASH)
BMA House, Tavistock Square, London, WC1H 9JP
Medical Foundation for AIDS & Sexual Health 2011
This publication is subject to disclaimers. See inside back cover for details.
Acknowledgements
MedFASH is grateful for advice, support and comments from a wide range of individuals
during the development of this booklet, including: Dr Hamish Meldrum, Chairman of
Council of the British Medical Association; Dr Ewen Stewart, Dr Philippa James and Dr Neil
Lazaro of the Royal Col ege of General Practitioners (RCGP) Sex, Drugs and HIV Group;
Professor Brian Gazzard of the Chelsea & Westminster Hospital and Dr John Hughes of the
BMA General Practitioners Committee, both serving Trustees of MedFASH.
Thanks are also due to the fol owing for help with drafting and information: Dr Laura Waters of Brighton & Sussex University NHS Trust; Dr Annemiek de Ruiter and Dr Graham Taylor of the British HIV Association; Professor Deenan Pil ay of University Col ege London; Dr Dan Clutterbuck, Consultant in genitourinary and HIV medicine, NHS Lothian/NHS Borders; Dr Louise Melvin and Julie Craik of the Faculty of Sexual and Reproductive Healthcare Clinical Ef ectiveness Unit; Dr Valerie Delpech and Meaghan Kal of the Health Protection Agency. Particular thanks are due to Dr Mark Nelson of the Chelsea & Westminster Hospital and Dr Patrick French of Mortimer Market Centre for technical advice and checking.
Sponsored by Bristol-Myers Squibb (BMS). Printing supported by Vi V Healthcare UK Ltd. Neither BMS nor Vi V have had any editorial input or control over the content of this booklet.
Il ustrations and figures are reproduced with the kind permission of Dr Nick Beeching of Royal Liverpool University Hospital, Dr Ben Riley of the RCGP's e-learning for Healthcare programme, Dr Valerie Delpech of the Health Protection Agency, Medical Il ustration UK Ltd and the Science Photo Library.
Project management: Russel Fleet, MedFASH Project Manager.
Editing: Ruth Lowbury, MedFASH Chief Executive.
Proofing: Jason Penn, BMA.
Design and layout: Tranter design, www.tranterdesign.com The authors are credited in alphabetical order. MedFASH would particularly like to thank them al for giving their time and expertise in revising and updating HIV in Primary Care.
Cover
CNRI/Science Photo Library
False colour transmission electron micrograph of human immunodeficiency virus particles
inside a stricken T4 lymphocyte, a white blood cel of the immune system.
HIV IN PRIMARY CARE 2nd edition SectIon 1 HIV – core InformatIon
HIV in the UK: the figures monitoring HIV in the UK: how is it done? The virus and the natural history of HIV infection Tests and clinical markers of HIV infection antiretroviral therapy HIV prevention in the UK SectIon 2 How to dIagnoSe HIV In prImary care
Opportunities to diagnose HIV in primary care The clinical diagnosis of HIV Primary HIV infection Clinical conditions associated with longstanding HIV infection HIV testing in primary care SectIon 3 clInIcal care for people wItH HIV
Patients with HIV Health promotion, screening and immunisation for people with HIV Sexual and reproductive health managing HIV-related problems Caring for people on antiretroviral therapy (arT) additional treatments for those with immunosuppression The patient who wil not attend for specialist care The dying patient HIV In PrImary Care 2nd edition SectIon 4 HIV and tHe practIce team
Sexual health promotion and HIV prevention in the practice Working with those with diverse needs Practice policies and systems SectIon 5 QuIck reference
HIV testing aide-memoire antiretrovirals by group Drug interactions – further information Drug side ef ects a guide to managing HIV-related problems Information to support implementation of UK HIV testing guidelines 97Useful sources for clinicians Professional development for clinicians on HIV and sexual health Useful sources for patients SectIon 6 Subject Index
Index of pHotograpHS
1. Herpes zoster 2. Opportunities to diagnose HIV in primary care 3. Primary HIV infection 4. Kaposi's sarcoma – legs 5. Kaposi's sarcoma – face 6. Seborrhoeic dermatitis 8. Oral hairy leukoplakia 9. Palatal Kaposi's sarcoma 11. Lipodystrophy HIV In PrImary Care 2nd edition


HIV remains one of the most important communicable diseases in the United Kingdom. Early diagnosis coupled with advancements in antiretroviral therapy have led to a substantial reduction in HIV-related deaths in the UK. However, over a quarter of people with HIV in the UK remain undiagnosed. This figure is particularly sobering in light of the significant links between late diagnosis and morbidity and mortality. evidence is clear that early diagnosis has long-term health benefits and allows for cost-effective management of HIV as a long-term condition, preventing expensive and distressing major medical interventions further down the line.
Primary care is in an ideal position to support the drive for early diagnosis of HIV and to facilitate the successful long-term management of HIV. GPs and other primary care health professionals have unique breadth and frequency of contact with patients – many of those diagnosed with HIV will have come into contact with primary care services prior to their diagnosis. GPs play a key role in facilitating a collaborative approach across primary and secondary care, particularly helping patients to navigate through the various specialties and agencies. This booklet is an excellent guide for GPs, practice nurses and primary care teams, providing accessible and comprehensive information about HIV diagnosis and treatment.
an open dialogue about HIV with our patients is crucial for HIV prevention, including the promotion of safer sexual and injecting practices. HIV in Primary Care provides valuable guidance about how to promote communication with patients across the primary healthcare team, as well as providing practical advice about how to spot the early signs and symptoms of undiagnosed HIV.
The management of HIV and treatment choices are complex and can seem daunting even to experienced healthcare professionals. This booklet includes practical advice relating to adherence to treatment HIV In PrImary Care 2nd edition regimens, the side effects of antiretroviral therapy and possible drug interactions with commonly prescribed medicines, as well as guidance on needlestick injuries, record keeping and other practical policies and procedures.
a diagnosis of HIV has huge ramifications for an individual, and HIV patients learning to live with their condition face particular and significant challenges which need to be dealt with in a sensitive manner. There is a need to acknowledge, for example, how important confidentiality, clear communication and continuity of care are to patients with HIV, and that maintaining a strong doctor-patient relationship is crucial for the successful management of chronic conditions such as HIV.
The Bma supports the medical Foundation for aIDS & Sexual Health and welcomes this guidance as an important tool in helping to raise awareness and equip primary care professionals to deal with the diagnosis and treatment of HIV.
Dr Hamish meldrumChairman of CouncilBritish medical association HIV In PrImary Care 2nd edition Preface
About this booklet
The number of people with HIV infection continues to rise. There is
no cure and no vaccine, although current treatments are life-saving.
Over a quarter of those with HIV infection in the UK have yet to be
diagnosed, even though many will be using primary care and other
medical services.
This booklet will provide essential information on HIV for GPs, practice nurses and other members of the primary healthcare team. The booklet provides information on:• HIV and the consequences of infection• the clinical diagnosis of HIV in primary care• HIV testing and prevention strategies in primary care• the management of those with HIV – with a primary care focus.
Comments about this booklet are welcome, and wil inform future editions. Please send them to the medical Foundation for aIDS & Sexual Health.
About the Medical Foundation for AIDS & Sexual
Health (MedFASH)
The medical Foundation for aIDS & Sexual Health (medFaSH) is an
independent charity dedicated to the pursuit of excellence in the
healthcare of people affected by HIV, sexually transmitted infections (STIs)
and related conditions. Originally established by the British medical
association, medFaSH has been undertaking a range of projects to
support and guide health professionals and policy-makers since 1987.
recent work includes developing national Standards for the management of sexually transmitted infections (STIs) with the British association for Sexual Health and HIV (BaSHH) and the Tackling HIV Testing resource pack, designed to support implementation of the UK National Guidelines for HIV Testing 2008. In 2007, working with the royal College of General Practitioners, (rCGP), medFaSH developed the Introductory Certificate in Sexual Health, a course for GPs, practice nurses and other primary care practitioners.
HIV In PrImary Care 2nd edition About the authors
Dr Sara Madge mBBS mrCGP works as an associate specialist at the royal Free Centre for HIV medicine in London, having worked in HIV/aIDS since 1992. She has a background in general practice.
Dr Philippa Matthews mBBS FrCGP is a GP in King's Cross, London. She is an Honorary Senior Clinical Lecturer at the University of Warwick. She has had an interest in HIV, sexual health and sexual history-taking in primary care for many years, particularly how to teach in a way that effects a change in practice. She is also interested in how best to develop and deliver sexual health services in general practice. She is a clinical advisor to the Sexual Health in Practice (SHIP) scheme and is currently involved in assessing to what degree SHIP teaching increases GP HIV testing rates. She was national Quality and Outcomes Framework (QOF) lead for sexual health from 2007-09. She has edited the e-GP Sexual Health and Contraception module and the FPa Handbook of sexual health in primary care. Dr Surinder Singh Bm mSc FrCGP is a senior lecturer at UCL and a GP with a long-standing interest in HIV and aIDS. He has been a senior partner in a thriving practice in Deptford, London since 1992. He was a member of the original Independent advisory Group on Sexual Health and HIV, established in 2002 as part of the Government's national strategy for sexual health and HIV in england. Latterly he has been a performance assessor for the GmC. Surinder is an enthusiastic advocate of point-of-care testing for HIV.
Dr Nick Theobald ma mSc mBBS trained in general practice in Bath and Wiltshire and was a GP principal in Swindon for nine years. He is currently associate specialist in HIV/genitourinary medicine at Chelsea and Westminster Hospital and Imperial College, London with responsibility for undergraduate and postgraduate education. He chairs the Sexually Transmitted Infection Foundation (STIF) Course Steering Group for BaSHH and has been module editor for the eHIV-STI programme.
HIV In PrImary Care 2nd edition HIV – cor1
In tHIS SectIon
HIV in the UK: the figures Monitoring HIV in the UK: how is it done? The virus and the natural history of HIV infection Tests and clinical markers of HIV infection Antiretroviral therapy HIV prevention in the UK HIV In PrImary Care 2nd edition


Section 1
HIV – core information
For those who need an update on HIV, its effects and how it is treated and prevented.
HIV in the UK: the figures
1. How common is HIV in the UK?
Human immunodeficiency virus (HIV) continues to be one of the most
important communicable diseases in the UK, with 86,500 people thought
to be infected by the end of 2009. a total of 6,630 persons (4,400 men
and 2,230 women) were newly diagnosed with HIV in 2009 (see figure 1).
The annual number of new diagnoses doubled in the first five years of the century and has since declined slightly, with over half (54%) of newly diagnosed individuals infected through heterosexual transmission (see figure 2). The majority of these infections were acquired abroad (see figure 3) and mostly in Sub-Saharan africa, though this group accounts Figure 1 HIV & AIDS diagnoses and deaths in HIV-infected individuals by year in the United Kingdom, 1990-2009 –––– HIV diagnoses
–––– AIDS diagnoses
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Health Protection Agency HIV In PrImary Care 2nd edition



HIV – core information
Section 1
Figure 2 New HIV diagnoses in the UK by year of diagnosis and exposure category 1990-2009 (adjusted for late reporting) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Health Protection Agency Figure 3 Heterosexually acquired infection by sub-category of heterosexual exposure, 1990-2009 (observed data unadjusted) –––– Heterosexual y acquired
infections (total) –––– Aquired in UK
–––– Acquired abroad
–––– Not known
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Health Protection Agency HIV In PrImary Care 2nd edition


Section 1
HIV – core information
Figure 4 Estimated number of HIV-infected adults aged 15-59 in the UK at the end of 2009 Injecting drug use
Number diagnosed Heterosexual
Number undiagnosed Heterosexual
Sex between men
Number of infected adults (in thousands) Source: Health Protection Agency for most of the recent decline. Of the heterosexuals newly diagnosed in 2009, about a third probably acquired their infection within the UK.
The annual number of new diagnoses in men who have sex with men (mSm) has steadily increased since 2001 from a stable level through the 1990s. It is estimated that four out of five acquired their infection in the UK. There are still high levels of HIV transmission in this group – one in five mSm newly diagnosed has probably become infected within the previous four to five months, according to new research from the Health Protection agency (HPa).
2. The impact of treatment on death rates in the UK
There has been effective treatment for HIV since the mid 1990s.
antiretroviral therapy (arT) and other interventions have resulted in a
dramatic reduction in the number of deaths among those diagnosed with
the infection (see figure 1), and for most people it is now a chronic
condition rather than an inevitably fatal illness.
3. Undiagnosed HIV
Based on anonymised seroprevalence surveys, it is estimated that over a
quarter of people living with HIV (26%, 22,000) remain undiagnosed (see
figure 4).
HIV In PrImary Care 2nd edition HIV – core information
Section 1
4. Late diagnosis
HIV-related morbidity and mortality are concentrated among those who
are diagnosed late. about half of all new HIV diagnoses are made at a
stage when arT should already have been started. although individuals
diagnosed late can do well, their life expectancy is reduced and their
treatment is likely to be more complex. In 2009, almost three-quarters of
UK deaths among people with HIV were in those who had been
diagnosed late.
There is evidence that a significant proportion of people diagnosed late with HIV have been seen in general practice within the previous year. Some presented with, in retrospect, HIV-associated symptoms but were not offered an HIV test (see page 97 for a list of indicator diseases).
early diagnosis improves health outcomes and is also more cost- effective as timely initiation of arT leads to fewer episodes of acute serious illness. arT also lowers infectiousness and the risk of transmission to others.
Monitoring HIV in the UK: how is it done?
1. Measuring diagnosed HIV infection
The HPa and Health Protection Scotland collect information on newly
diagnosed HIV infections, aIDS diagnoses and deaths based on voluntary
case reporting by laboratories and clinicians. In addition, annual surveys
of adults attending for HIV-related care provide a geographical distribution
of diagnosed cases as well as information on uptake of antiretroviral
therapy.
2. Measuring undiagnosed HIV infection
The Unlinked anonymous Seroprevalence Surveys provide data on the
prevalence of HIV infection in selected adult populations (pregnant
women, sexual health clinic attendees and injecting drug users). Blood
samples taken in participating centres for other reasons are irreversibly
unlinked from patient identifying information and tested anonymously for
HIV. The surveys help monitor trends in the prevalence of both diagnosed
and undiagnosed HIV infection in these settings. Participants are always
offered an HIV test as part of these surveys.
3. Measuring the length of time of infection
new laboratory tests (‘incidence tests') are available that are being used
in HIV surveillance to help distinguish recent infection (acquired within the
last four to five months) from longstanding infection. This surveillance,
known as the recent Infection Testing algorithm (rITa), is providing useful
information on incidence and HIV transmission dynamics at a population
level. However, there are currently significant difficulties in interpreting
results for individual patients because of confounding factors that can
distort the results.
HIV In PrImary Care 2nd edition


Section 1
HIV – core information
The virus and the natural history of HIV infection
For more on
primary HIV
1. The human immunodeficiency virus
infection see
HIV is a retrovirus which preferentially infects immune system cells – particularly a class of T lymphocytes called CD4 cells (also known as T helper cells). It is present in an infected person's blood and in other body fluids, including semen, vaginal secretions and breast milk.
a flu-like illness is common in the first few weeks after infection and may be mild or quite severe. During this phase called ‘primary HIV infection' (also known as HIV seroconversion illness) there are large amounts of replicating virus and the patient is very infectious.
Once the symptoms of primary HIV infection subside, an asymptomatic stage of infection begins. There are usually no overt clinical signs or symptoms of HIV infection during this stage. There is a wide variation in the time it takes to progress to symptomatic disease and the individual may be well for many years even though the virus is actively replicating. Ultimately the normal levels of CD4 cells can no longer be maintained and as their numbers decline the immune response is undermined.
2. The consequences of HIV infection
Opportunistic infections

For more on
If untreated, infection with HIV results in the development of HIV-associated clinical problems
opportunistic infections (OIs). Fungi, viruses, bacteria and other organisms caused by HIV
that are usual y control ed by a healthy immune system can al cause OIs. infection see page
Some, such as candidiasis or herpes zoster, are more common in the immunocompromised. Others, such as Pneumocystis pneumonia (PCP) only cause infection in the Herpes zoster. Commoner in those who are immunocompromised, this condition is one of the opportunistic infections associated with HIV.
Malignancies
Some malignancies are associated
with HIV infection including
Kaposi's sarcoma (KS), non-
Hodgkin's lymphoma and
carcinoma of the cervix. When
diagnosed in an HIV-positive
patient, these cancers classify the
individual as having developed
aIDS. Other cancers including
cancer of the lung, Hodgkin's lymphoma and some skin cancers may also occur at a higher rate in the HIV-infected patient.
HIV In PrImary Care 2nd edition HIV – core information
Section 1
Direct effects
HIV itself causes a flu-like illness in the weeks after infection. In advanced
disease it may also cause wasting, diarrhoea and neurological problems,
although these may also be caused by OIs.
3. Acquired Immune Deficiency Syndrome (AIDS)
The term aIDS was coined before HIV was identified in order to help
classify and monitor a new medical condition. There are now much better
measures of disease progression (see pages 17-18) and it is more
common to refer to ‘advanced HIV disease'. Thus ‘aIDS' now has limited
value with respect to prognosis. It is, however, still used as a category in
epidemiological surveillance and in resource-poor countries.
a patient is said to have aIDS when they develop certain conditions. as well as the malignancies described above, infections leading to an aIDS diagnosis include: Pneumocystis pneumonia (PCP), cytomegalovirus (CmV), progressive multifocal leucoencephalopathy (PmL), Mycobacterium avium intracellulare (maI), cryptococcosis, cryptosporidiosis and toxoplasma encephalitis.
Tests and clinical markers of HIV infection
1. Combined HIV antibody and P24 antigen tests
The most commonly used test to diagnose HIV looks for both the HIV-1 and
HIV-2 antibodies as wel as a protein of the virus, the HIV p24 antigen. These
‘fourth generation' tests are an improvement on previous HIV tests which
looked for antibodies only. The combined test should be available to the
majority of GPs in the UK and this can be confirmed with the local lab. In the
event of a positive result a second sample is requested for confirmation. The
test gives no indication of disease progression.
2. The ‘window' period
antibodies to HIV typically appear four to six weeks after infection, but
this may occasionally take as long as 12 weeks. The p24 antigen can be
detected in a blood sample within two to five weeks, but it rapidly
becomes undetectable once antibodies to HIV start to develop. The
period between becoming infected and antibodies developing is
commonly referred to as the ‘window' period. See box for current British
association for Sexual Health and HIV (BaSHH) guidance on
interpretation of the combined antibody/antigen tests.
HIV In PrImary Care 2nd edition Section 1
HIV – core information
USEFUL INFO
BASHH Statement on HIV window period, 15 March 2010
• HIV testing using the latest (4th generation) tests is recommended in the BHIVA/BASHH/ BIS UK National Guidelines for HIV Testing (2008). These assays test for HIV antibodies and p24 antigen simultaneously. They will detect the great majority of individuals who have been infected with HIV at one month (four weeks) after specific exposure.
• Patients attending for HIV testing who identify a specific risk occurring more than four weeks previously, should not be made to wait three months (12 weeks) before HIV testing. They should be offered a 4th generation laboratory HIV test and advised that a negative result at four weeks post exposure is very reassuring/highly likely to exclude HIV infection. An additional HIV test should be offered to all persons at three months (12 weeks) to definitively exclude HIV infection. Patients at lower risk may opt to wait until three months to avoid the need for HIV testing twice.
3. Polymerase chain reaction (PCR) tests
These quantitative assays are a form of nucleic acid amplification Test
(naaT). They are not often used as an initial diagnostic test for HIV in
adults as they are expensive and can risk a high false positivity rate in the
absence of laboratory interpretation. However, they are now the preferred
test used by specialists if primary HIV infection is suspected and the
antibody/antigen test is negative.
4. Point-of-care tests
most point-of-care tests (POCTs) use rapid testing devices which look for
antibodies only on oral fluid or pinprick blood samples, and a test result
can be given within 15 minutes of the specimen being taken. There are
now rapid tests which look for p24 antigen as well as antibodies. The
specificity of rapid testing devices is lower than that of standard
laboratory tests and, in low prevalence settings, this may result in a
significant proportion of positive results being false positives. It is essential
that all reactive POCT results are confirmed with a conventional blood
test. The use of POCTs should be discussed with your local HIV specialist
and virology lab – the validity of the tests in your local area is of
paramount importance.
POCTs are useful in situations such as when a sick patient presents to the emergency Department or a woman of unknown HIV status is in labour. They are also used in community outreach testing and are being used in HIV screening pilots in primary care and acute settings (see page 46).
HIV In PrImary Care 2nd edition HIV – core information
Section 1
5. CD4 lymphocyte cell count (CD4 count)
The CD4 count is an indicator of the degree of immunosuppression in
those infected with HIV. In healthy, non-HIV-infected individuals the CD4
count is usually above 500 cells/μl, although some have naturally lower
CD4 counts. CD4 counts are variable – for example, if someone has a
cold or has recently had an immunisation. Overall trends are more
important than single readings.
The CD4 count declines at a rate of approximately 40-80 cells/μl per year in untreated individuals with HIV, but some infected individuals progress faster than others. There is wide variation in the time it takes to progress from primary infection to symptomatic disease (see figure 5). Patients with a CD4 count of below 200 cells/μl are at most risk of HIV-related OIs and tumours, but some may not have significant symptoms.
CD4 counts are the main determinant in deciding when to start arT and when to commence prophylaxis against OIs. The table below is a guide showing how CD4 counts can be correlated with the risk of developing particular HIV-related problems – but there will always be some exceptions.
How CD4 counts correlate with HIV-related problemsCD4 count Risk of opportunistic infection Risk of HIV-associated Hodgkin's disease Bacterial skin infections recurrent bacterial chest infections Oropharyngeal candida Fungal infections (skin, feet, nails) Seborrhoeic dermatitis Oral hairy leukoplakia non-Hodgkin's lymphoma Weight loss Persistent herpes simplex infections Oesophageal candida Cryptococcal meningitis Cerebral toxoplasmosis Cytomegalovirus infections Primary cerebral Mycobacterium avium intracellulare Reproduced with permission from e-gP: e-learning for general Practice (www.e-gP.org) Royal col ege of general Practitioners 2010. opportunistic infection column adapted from: leake-Date H & Fisher m HIV Infection. In: Whittlesea c & Walker R (eds) (2007) Clinical Pharmacy and Therapeutics 4th Edition. oxford: churchil livingstone.
HIV In PrImary Care 2nd edition Section 1
HIV – core information
6. Viral load
This is a measure of the amount of HIV in the blood, determined using a
PCr test (see page 16), and reflects rates of viral replication. The viral
load should fall if arT is acting effectively. a rising viral load in a patient on
arT can indicate a range of problems, for example the patient may not
be adhering to their regimen or it may be associated with resistance to
one or more antiretroviral drugs. Viral load can range from undetectable
(defined as the sensitivity of the test – currently less than 50 copies of viral
genome/ml of blood) to over a million copies/ml. numbers of copies/ml
are often expressed in a log scale (eg 106 copies/ml). The degree of viral
replication is linked to the rate of CD4 decline and hence disease
progression.
7. How the CD4 count and viral load interrelate
a high viral load predicts a more rapid CD4 decline. The CD4 count of
those not taking arT and who have a high viral load is likely to fall more
rapidly than that of those with a lower viral load (see figure 5). When the
viral load is suppressed CD4 counts recover with a lower risk of
developing OIs, tumours and other complications.
Figure 5 Association between virological, immunological and clinical events, and time course of HIV infection in an untreated individual dramatically during Time after infection Reproduced with permission from e-gP: e-learning for general Practice (www.e-gP.org) Royal col ege of general Practitioners 2010 HIV In PrImary Care 2nd edition HIV – core information
Section 1
antiretroviral therapy (arT) has had an enormous impact on morbidity and mortality from HIV disease in the UK (see figure 1). new drugs and For more on ART
strategies are continually being developed.
and side effects
The management of HIV has become complex with the advent of arT. see pages 67-74
This section gives a brief overview of the current specialist management of HIV. For aspects of management that may be encountered by the GP, see the guide to managing HIV-related problems on pages 93-96.
arT limits HIV replication with the aim of reducing viral load to undetectable levels. HIV mutates as it replicates and if drugs are used singly resistance develops rapidly. Therefore, drugs are most often used in combinations of three or more. adherence to drug regimens is essential.
antiretroviral drugs are classified into five groups, according to where and how they act in the replication cycle of the virus. They are:• nucleoside/tide reverse transcriptase inhibitors (nrTIs)• non-nucleoside reverse transcriptase inhibitors (nnrTIs)• protease inhibitors (PIs)• integrase inhibitors (IIs)• entry inhibitors (eIs).
The effectiveness of arT is monitored by measuring viral load (see page 18). Blood samples can also be tested for drug resistance to help determine the best combination of antiretroviral drugs to use.
after arT has started, drugs may be changed according to any side effects experienced. These can include serious conditions such as hyperlipidaemia, diabetes and lipodystrophy (a syndrome characterised by redistribution of body fat).
HIV prevention in the UK
at a strategic level, efforts to promote sexual health target those in groups associated with a high risk of HIV. It is sensible, for example, to prioritise interventions supporting safer sex with gay men, or projects working on knowledge of HIV and transmission risks among african communities. However, when faced with an individual patient from one of these groups, those working in primary care should make no assumptions about risk. each individual's risk needs to be assessed. For For more detailed information on sexual history- more on assessing risk, see page 45.
taking, risk assessment and sexual health promotion, see Sessions 11 001 to 11 003 on www.e-gP.org.uk HIV In PrImary Care 2nd edition Section 1
HIV – core information
1. Promoting safer sexual practices
Penetrative sex
Condom use significantly reduces sexually transmitted infections (STIs)
and HIV transmission from both vaginal and anal sex. Condoms should
be worn before penetration, and water-based or silicone-based lubricants
should be used. Oil-based lubricants degrade latex. Condom failure is
more often a function of inadequate lubrication and incorrect fitting than
condom thickness. People at risk of acquiring or transmitting HIV should
use condoms consistently.
See Department of There is evidence that oral sex, which is common in both heterosexual Health (2006) Oral and homosexual relationships, can allow HIV transmission – especially in the presence of oral disease (ulceration, gingivitis). For a small number of transmission of HIV individuals this is the only risk factor in acquiring HIV infection. However, – statement of risk at www.dh.gov.uk oral sex is very low risk for HIV transmission, especially if ejaculation in the mouth is avoided.
2. Preventing mother-to-child transmission
With appropriate interventions the transmission rate of HIV from mother to (2008) Guidelines baby (vertical transmission) can be reduced to under 1 per cent. for the management of HIV infection in achieving this depends on detecting HIV before pregnancy, or, failing that, pregnant women at in early pregnancy, when the chances of achieving viral suppression by the time of delivery are greatest.
Interventions to prevent vertical transmission include:• antiretroviral therapy in pregnancy• antiretroviral treatment at delivery plus a short course for the baby• elective Caesarian section (although vaginal delivery is an option for women on arT with an undetectable viral load) • avoidance of breastfeeding.
The ideal time to detect HIV infection is before the woman becomes pregnant. Offering HIV tests routinely to women using contraception – alongside tests for rubella immunity and haemoglobinopathy screens – is good practice, particularly in high prevalence areas. remember that women may need to be offered further HIV tests if there has been a risk of infection.
all pregnant women should be offered screening See the Infectious Diseases in Pregnancy for hepatitis B, HIV, rubella susceptibility and syphilis Screening Programme Standards at http:// as an integral part of their antenatal care during their first and all subsequent pregnancies.
HIV In PrImary Care 2nd edition HIV – core information
Section 1
3. Preventing transmission among injecting drug users
Preventing injecting drug use through education and information strategies is one approach. For those already injecting drugs, there are: indicates
• services that support people trying to quit and that prescribe safer substitutes such as methadone or buprenorphine conditions
• services to support safer injecting practices. needle exchanges are or highly
available in the community where drug users can exchange used important
needles and syringes for new replacements on an anonymous basis.
4. Risk reduction for people with diagnosed HIV
People with diagnosed HIV infection should follow safer sex and safer
drug use practices as described above. For more on sexual and
reproductive health issues for people with diagnosed HIV, see Section 3,
pages 61-64.
5. Providing post-exposure prophylaxis (PEP): an emergency
PeP is the emergency use of arT to prevent infection when a person has
been exposed to a known or high risk of HIV transmission. The aim is to give arT as soon as possible after exposure (within hours, to a maximum of 72 hours). The exact choice of drug combination requires expert For PEP fol owing
guidance. The medication, usually taken for four weeks, can have significant side effects and many people are unable to continue working exposure see
while taking it.
PEP may be appropriate:
• following occupational exposure – see page 87 for management of
needlestick injuries and PeP • when an uninfected individual has had sex without a condom with a sexual partner known to have HIV or following sexual assault – see page 81 for post-exposure prophylaxis following sexual exposure (PePSe).
6. Screening blood and treating blood products
all blood donations in the UK have routinely been screened for HIV since
1985. all blood products in the UK are heat-treated to destroy HIV and
other blood-borne viruses.
7. Immunisation
There is little prospect for an effective vaccine against HIV in the near
future.
HIV In PrImary Care 2nd edition Section 1
HIV – core information
HIV In PrImary Care 2nd edition In tHIS SectIon
Opportunities to diagnose HIV in primary care The clinical diagnosis of HIV Primary HIV infection Clinical conditions associated with longstanding HIV infection HIV testing in primary care HIV In PrImary Care 2nd edition


Section 2
How to diagnose HIV in primary care
How to diagnose HIV People who are unaware that they have HIV are attending primary care. Which symptoms and conditions may be clues to HIV infection? How should HIV testing be approached in primary care? Opportunities to diagnose HIV in primary care
There are two circumstances which provide valuable opportunities to diagnose HIV infection in primary care:• when the patient presents with symptoms or medical conditions possibly associated with HIV – this is discussed in the first part of See the UK National Guidelines for HIV • offering an HIV test to an asymptomatic patient Testing 2008 at www.bhiva.org, because they are or may be at risk of HIV infection – www.bashh.org and www.britishinfection.org this is included in the second part of this section.
Opportunities to diagnose HIV in primary care. Be aware of symptoms and risks for HIV.
NIA ReeVe/ScIeNce PHo HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Talking to patients about HIV
This may be challenging to the clinician, especially if raising the subject with someone
who is not expecting it. In this section we suggest verbal strategies that may be used in a
variety of clinical situations. These are indicated in the speech bubbles on pages 47-49.
There are three important principles
Be open with the patient about the clinical reasoning behind your questions
a patient with a skin rash who is suddenly asked ‘Can I ask if you are gay?' will wonder
what the doctor is up to and, if he is gay, whether it is wise to answer honestly. If the
doctor first lays out the clinical grounds for asking the question, the patient may be better
prepared to give a full history. There are examples of how to do this later in the booklet.
Be non-judgemental
It is advisable to be direct but sensitive in your questioning. The more accessible and
understanding you appear, the more trusting the patient wil be, and the more accurate the
replies. If the patient perceives the clinician to be disapproving or judgemental, they wil be
more likely to withhold information and may not return for future care and fol ow-up.
Ensure your service is (and is seen to be) confidential
Patients may have concerns about confidentiality, in primary care in
particular. This may inhibit open discussion of personal issues. ensure
For practice
your practice develops a confidentiality policy and implements it policies and
through training and induction. Let your patients know that the policy systems see
is in place by displaying a confidentiality statement.
The clinical diagnosis of HIV
There is evidence that a significant proportion of people who present late with HIV infection have been in contact with doctors in preceding years with symptoms which, in retrospect, were related to HIV. Late diagnosis of HIV infection contributes substantially to morbidity and mortality. more advanced disease leaves people vulnerable to overwhelming infection until their CD4 count has risen in response to treatment.
The clinical diagnosis of HIV-related conditions in primary care is not always easy. many problems associated with HIV are commonly seen in people without HIV infection, for example, seborrhoeic dermatitis, shingles, folliculitis or a glandular fever-like illness. It barely seems feasible to consider HIV first – and then to raise it – whenever common conditions such as these present in the surgery.
nevertheless, the GP is familiar with the concept of considering rare but serious conditions when extremely common symptoms present. We HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
make quick assessments to answer questions such as ‘Could this febrile child have meningitis?' or ‘Could this headache be due to a brain tumour?' In this section we try to give the GP a realistic and pragmatic approach to improving their chances of detecting HIV infection.
There are two main clinical opportunities for diagnosing symptomatic HIV infection in primary care:• primary HIV infection • conditions associated with longstanding HIV infection.
These are dealt with in turn.
Primary HIV infection
An HIV test is likely to be positive in primary infection, but it may be Primary HIV infection (PHI – also negative (see page 27). If in known as seroconversion illness) doubt, re-test in a week.
occurs soon after infection – usually between two and six weeks. Symptoms develop in over 60 per cent of people at this stage. They may be mild and non-specific, but can also be marked and precipitate a consultation with the GP and, occasionally, hospital admission. even a very HIV-aware doctor is likely to miss some patients with PHI.
Diagnosis of primary HIV infection is valuable because:• the next opportunity for diagnosis may be at a late stage of disease progression, and so the Primary HIV infection. A blotchy rash on the trunk is prognosis for the patient is likely sometimes present two to six weeks after infection with HIV.
to be much worse• identifying the infection may protect others from becoming infected.
Symptoms and signs of PHI
The patient may have none,
some or all of these:
• fever
• sore throat
• malaise/lethargy
• arthralgia and myalgia
• lymphadenopathy.
If you are thinking of glandular fever, remember to consider primary HIV infection.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Symptoms and signs that are sometimes present and are more specific to PHI include:• a blotchy rash affecting the trunk• orogenital or perianal ulceration.
Other features that are less commonly present include:• headache or meningism• diarrhoea.
The CD4 count may drop acutely (albeit temporarily) at this stage of HIV infection, and so acute conditions associated with immunosuppression may also occur, including:• oral candidiasis• shingles• other conditions associated with immunodeficiency (see pages 29-38).
What to do if you suspect primary HIV infection
nothing is going to make this an easy consultation. as the symptoms can resolve within
three weeks, you will need to act quickly if you think the patient has PHI.
1. Take a history and conduct an examination to look for further evidence of PHI. Has the person had a rash? Or sores or ulcers in the mouth or genital area? 2. If you remain concerned, raise it with the patient. "Illnesses like this are usually caused by viruses, for example the glandular fever or flu virus. Some quite rare viruses can also be a cause, and it is important that I don't miss them if they occur. I don't know if you are at risk, but HIV is one of these." assess risks within the last 12 weeks. "Could I ask you a few questions to see if you could be at risk?" 3. If the patient has an identified risk for HIV or they have other clinical features of PHI, do the test and offer safer sex advice at this point. The result will be back in about a week so make an appointment for them to attend.
4. If the result is positive, arrange referral to HIV specialist services. If negative, retest (one week after the first test), reiterating the safer sex For more on
assessing risk see
5. If the second result is negative, this is highly likely to exclude PHI.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
case study
a man with a flu-like illness
fully with his partner at home, and had Ian, a 28-year-old white British male, had decided to have a test. Having spoken to an been registered with the practice two years, on-call microbiologist, the GP was aware but had only attended once before, for that the local lab offered combined antigen/ smoking cessation advice. He attended his antibody tests as standard. She took a GP saying he had flu and felt dreadful. He sample and the test was found to be HIV p24 said he was exhausted and was now in the antigen positive, but antibody negative, eighth day of his illness. He had a sore confirming primary HIV infection. Ian was throat, ached all over and initially distressed and felt feverish.
It was the severity and overwhelmed by feelings of It was the severity and duration of the symptoms guilt. Hospital follow-up duration of the symptoms was arranged.
that made the GP that made the GP consider Ian's long-term partner, consider glandular fever glandular fever and HIV. Wil , was also registered and HIV. First, she asked First, she asked Ian about with the practice. The Ian about rashes (he had rashes (he had none) and couple were seen together none) and oral and genital oral and genital ulceration. and it was established that Ian said he had mouth ulceration. Ian said he they had had one episode ulcers. On examination the had mouth ulcers. On of unprotected sex between GP could see three.
examination the GP could the time Ian had contracted After discussing the infection and the time he glandular fever, the GP initial y saw the GP. Then raised the subject of HIV and explained that they didn't have sex until some time after HIV very rarely an illness like this might be infection was confirmed. Wil tested negative caused in the early weeks of HIV infection. both initial y and three months later. Six The GP took a partner history and months after this the relationship had survived established that Ian lived with his male and the couple were continuing to practice partner, a relationship of six years. Ian safer sex. Ian was optimistic and had returned indicated that he felt that his relationship was to work. The couple told the GP that they felt mutually monogamous. There was no history that Wil had been saved from getting HIV of drug use.
because she had been ‘so on the bal '.
The discussion appeared to make Ian anxious, so the GP said: ‘On the basis of what you have told me your illness is unlikely • Some men who have sex with men may to be primary HIV infection.' She asked Ian if initial y not volunteer – or be reluctant to he would be interested in having an HIV test disclose – information about their sexual life.
‘in any case' and he said he would consider • General practice is well placed to support it. Ian returned within a week and explained the partners of HIV-positive people.
that he had had unprotected sex five weeks • Sexual partners of anyone diagnosed with before with a new partner he had met in a HIV should be offered an HIV test as club. He had now discussed the situation HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Clinical conditions associated with longstanding
Problems associated with HIV infection may be subtle and insidious, and patients may recover and be well for some time before encountering another problem. Subtle symptoms may mask serious illness, and conditions GPs may have been trained to think were Don't miss urgent or life-threatening harmless may indicate HIV disease.
conditions. Don't miss PCP! ! When you encounter any of the
Memorise the conditions in this section that are conditions given in this section, allow highlighted as urgent by the symbol above.
the thought of HIV to go through your Most serious problems usually occur at very mind. The stakes are high for these low CD4 counts (below 100) so other clinical clues patients – HIV diagnosis at this to immunosuppression are likely to be present.
presentation may be life-saving. The Pneumocystis pneumonia (PCP) is an possibility of immunosuppression is exception to this rule as it tends to occur at higher especially important to explore if: CD4 counts (below 200). It may be the first HIV- • the patient has had more than one related problem for which the patient seeks of the conditions listed below in the advice. The prognosis correlates directly with how preceding two or three years; or early or late the infection is identified and treated: • the patient has had unusually PCP can kill if diagnosed too late.
severe or difficult to treat forms of the conditions listed below.
There are many examples of patients being referred to secondary care with these symptoms without For table of
being tested for HIV. This delays diagnosis and wastes time and money clinical indicator
with patients attending general medical outpatient clinics for expensive conditions see
(and frequently irrelevant) investigations. It may also put others at risk of acquiring HIV.
Guidance for assessing problems that may be HIV-related
• Enquire about weight loss, sweats, diarrhoea
• Examine the patient for other signs of immunosuppression (mouth, skin and nodes)
• Review the records for evidence of HIV-associated problems
(see list pages 30-38) • Discuss the possibility of HIV with the patient to consider their risk Mouth, skin and
• Decide on priorities: is urgent assessment by a specialist required nodes see
or can an HIV test be offered? pages 35-37
Think HIV and be prepared to offer the test – don't assume someone else will do it! HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
The UK National Guidelines for HIV Testing 2008 contain tables of clinical indicator diseases for adult and paediatric HIV infection. They list conditions that are aIDS-defining in the patient who is known to be HIV-positive; in patients whose HIV status is unknown these are indicator conditions and should usually prompt the offer of an HIV test. The tables are reproduced at the end of this booklet in the Quick reference section. Where conditions listed in the table are mentioned in this section, this is highlighted in a ‘Guidelines recommend' box.
1. Respiratory conditions
Cough, sweats, shortness of breath and weight loss may be caused by several opportunistic infections, including community-acquired bacterial infections. Pneumocystis pneumonia (PCP) is the most important infection not to miss in the short term. TB is also important. Occasional y, lymphomas or Kaposi's sarcoma may af ect the lungs in HIV-infected patients.
! This is a life-threatening infection with symptoms which often have an
insidious onset progressing over several weeks. arguably, PCP is the single most dangerous trap for the unwary GP as it may be the first HIV-related clinical problem the patient has. The prognosis correlates directly with how early or late the infection is identified and treated: PCP can kill if diagnosed late.
Symptoms
• a persistent dry cough of a few weeks' duration
• increasing shortness of breath or decreasing exercise tolerance
(clinicians should ask because patients may not mention it) • difficulty in taking a full breath (this reflects loss of elasticity of the • fever (in most but not all).
assessment
The chest is often clear on auscultation – especially in early stages. Fine
crackles may be heard. Chest X-rays may reveal little and can lead to
delay. The GP may be thinking of asthma, an atypical chest infection or
anxiety. If PCP is a possibility, look for evidence of HIV: see the guidance
on assessment above and also boxed information on page 38.
management/referral
refer the patient urgently if you are concerned they may have PCP, which
can only be diagnosed by hospital-based tests such as induced sputum
and bronchoscopy. an HIV test may cause inappropriate delay.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
This condition is also important to detect in any patient known to have HIV, even if they are on medication to prevent this. PCP is most often seen in those with CD4 counts of less than 200 cells/μl, but about 10 per cent have a CD4 above 200 cells/μl, so a CD4 at this level should not be a reason to exclude PCP.
TB and atypical mycobacterial disease
TB is an important and common presenting problem in HIV-infected
patients in the UK. It can occur at CD4 counts above 200. People See case study
with HIV are more likely to develop symptoms and/or systemic infection with TB than those without HIV.
atypical mycobacterial disease (Mycobacterium avium intracellulare) is a less common complication, associated with late-stage HIV infection.
The patient may have a cough, fever, sweats, shortness of breath, weight loss or haemoptysis. They may have associated large, asymmetrical Mycobacterium avium intracellulare may present with systemic symptoms and chest symptoms may or may not be present. abnormal liver function tests and anaemia may be found.
tested for HIV.
assessment
as for TB in the HIV-negative (eg CXr), but look for evidence of HIV: see
guidance on assessment on page 29 and also boxed information on
page 38. Mycobacterium avium intracellulare is very unlikely in a patient
without several clinical pointers to HIV disease because it occurs at very
low CD4 counts.
management/referral
Urgent outpatient or inpatient referral will be required,
For guidance on
although an HIV test could also be arranged and may assessment see
save time if the patient is not too unwell.
box on page 29
Community-acquired chest infections
Chest infections which respond to the antibiotics usually employed in community settings are commoner in immunosuppressed patients.
Anyone with bacterial Look for evidence of HIV: see guidance on assessment on page 29, and also boxed information on page 38.
offered an HIV test.
management/referral
as usual for chest infections, but offer an HIV test if appropriate.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
2. Conditions causing neurological and visual symptoms
Guidelines recommend a great variety of intracranial or peripheral neurological problems may occur in relation to HIV infection. Symptoms and signs include: • headache, neck stiffness or photophobia • focal neurological signs suggesting intracranial space occupying lesion (for example, lymphoma) • peripheral neuropathy (especially sensory change or loss) • confusion, memory loss, or disinhibition peripheral neuropathy This may present with headaches without the classical symptoms or signs of meningism.
assessment
apart from a neurological assessment and general examination, look for
evidence of HIV. See guidance on assessment on page 29.
management/referral
The patient will need to be referred urgently. an HIV test may cause
inappropriate delay if the patient is very unwell.
Toxoplasmosis
This may present with headaches, fever and focal neurological signs
which may be progressive.
assessment
apart from a neurological assessment and general examination, look for
evidence of HIV. See guidance on assessment on page 29.
management/referral
The patient will need to be referred urgently. Waiting for an HIV test may
cause inappropriate delay if the diagnosis is suspected.
Cerebral lymphoma
This may present with headaches, fever and focal neurological signs
which may be progressive.
assessment
apart from a neurological assessment and general examination, look for
evidence of HIV. See guidance on assessment on page 29.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
management/referral
The patient will need to be referred urgently. Waiting for an HIV test may
cause inappropriate delay if the diagnosis is suspected.
Cytomegalovirus (CMV) infection of the retina
CmV infection of the retina causes blindness and can be treated, but earlier diagnosis improves the prognosis. It is mostly found in those who have CD4 counts of less than 100 cells/μl.
The patient may have: For CD4 counts
• reduced vision see page 17
• scotomas.
retinopathy should be Changes may be visible on fundoscopy, but the absence of changes should not alter management. Look for For guidance on
evidence of HIV: see guidance on assessment on page assessment see
29. CmV retinitis is very unlikely in a patient without box on page 29
several clinical pointers to HIV disease, because it occurs at very low CD4 counts.
management/referral
The patient will need to be referred urgently to ophthalmology. Waiting for
the result of an HIV test may cause inappropriate delay if the patient is
very unwell.
Kaposi's sarcoma. This tumour is associated with immunosuppression and has a variety of appearances on the skin.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
3. Tumours associated with HIV
Guidelines recommend Lymphoma may cause lymphadenopathy, fevers, night sweats and abdominal masses. It may be cerebral (see neurological problems, Look for evidence of HIV. See guidance on assessment on page 29.
offered an HIV test.
management/referral
as for any suspected cancer.
Cervical carcinoma
Cervical cancer may cause vaginal bleeding or discharge. Cytological
abnormalities may also be a marker for underlying HIV infection.
assessment and management/referral
as normal for suspected cervical cancer. Offer an HIV test if appropriate.
Kaposi's sarcoma (KS)
These tumours may occur in a variety of places. They most commonly
appear as dark purple or brown intradermal lumps that sometimes look
! like bruises (but feel harder). KS may also be found in the mouth.
Infiltration of the lungs or gut is rare but can be very serious, the latter causing GI bleeding.
assessment and
Kaposi's sarcoma. This tumour may also rarely affect refer to HIV specialist, may require urgent medical admission if lung or gut involvement.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
4. Constitutional symptoms associated with HIV
Constitutional symptoms may be caused by HIV itself, or by a Guidelines recommend related opportunistic infection (such as TB) or tumour (such as a lymphoma). Symptoms include: mononucleosis-like weight loss of >10kg or See case study
lymphadenopathy of • lymphadenopathy (HIV is particularly likely if unknown cause should this persists in excess of three months, in be offered an HIV test.
two or more extra-inguinal sites and in the absence of any other cause).
assessment
Look for evidence of HIV.
For guidance on
assessment see

Urgent assessment is sometimes appropriate. For outpatient referrals box on page 29
arrange an HIV test beforehand to ensure that the appropriate clinic is identified and inform them of the result. For inpatient referrals, highlight the need for HIV testing in the referral letter.
5. Skin conditions
See case study
Look out for common skin conditions that are particularly severe or hard to treat. review the records for other evidence of HIV infection. examples include:• fungal infections, such as tinea cruris, tinea pedis, Seborrhoeic dermatitis. This pityriasis versicolor common condition may give a clue • viral infections, such as shingles (especially if to immunosuppression, especially more than one dermatome is affected), Molluscum if severe or difficult to treat.
contagiosum, warts and herpes simplex • bacterial infections, such as impetigo, fol iculitis• Kaposi's sarcoma (see above for description)• other skin conditions, such as seborrhoeic dermatitis and psoriasis assessment
Look for evidence of HIV. See guidance on
assessment on page 29, and also boxed information as usual, and arrange an HIV test if appropriate.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
6. Conditions affecting the mouth
Immunosuppression can lead to a number of conditions affecting the mouth and examination of the mouth is key in assessment as some of the conditions may be asymptomatic. examples include: Anyone with oral • oral candidiasis (thrush): not just a coated tongue, but thick white plaques on the buccal mucosa that could be scraped off with a tongue depressor. Oral candida can also have a red, fleshy appearance with fewer – or no – plaques and in this case can be harder to diagnose. Swabs are of little diagnostic value because of high carriage rates. Florid oral thrush should always lead to a consideration of whether the patient could be immunosuppressed • aphthous ulceration• oral hairy leukoplakia: causing whitish corrugations, typically on the side of the tongue. They cannot be scraped off. It is usually asymptomatic, but is pathognomic of immunosuppression. It is useful to look for this if you suspect a patient may have HIV disease (see photo on page 37) • Kaposi's sarcoma: purple tumour, characteristically on the palate• gingivitis• dental abscesses.
assessment
Look for evidence of HIV: see guidance on assessment on page 29, and
also boxed information on page 38.
management/referral
as usual and arrange an HIV test if appropriate.
7. Conditions affecting the upper and lower GI tract
Significant conditions include:
Guidelines recommend • oesophageal candidiasis: the patient presents with dysphagia suggestive of an oesophageal problem, but is highly likely to have concurrent oral thrush chronic diarrhoea or • diarrhoea – persistent mild, or severe acute. There may be virtually any – or commonly no – causative organism found.
oral/oesophageal Look for evidence of HIV.
For guidance on
assessment see

box on page 29
as usual and arrange an HIV test if appropriate.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Left to right:1. Oral candida. This condition is an important indicator of immunosuppression.
2. Oral hairy leukoplakia. Pathognomic of immunosuppression.
3. Palatal Kaposi's sarcoma. This tumour gives another reason for careful examination of the mouth when looking for evidence of HIV.
INDel AND TeNNANT-Flo 8. Genital problems
Sexually transmitted infections (STIs) such as genital herpes or genital warts may be more severe in the immunosuppressed patient. In addition, severe or difficult to treat genital candida may itself be a clue to immunosuppression. The diagnosis of any STI should lead to a consideration of the possibility of other STIs, including HIV.
See case study
Look for evidence of HIV: see guidance on assessment on page 29, and also boxed information on page 38.
See also cervical
as usual and arrange an HIV test if appropriate.
cancer page 34
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
9. Haematological problems
Changes found on routine full blood counts may give a clue to immunosuppression. They may be severe enough to require urgent action, but are often more subtle, with few symptoms. Guidelines recommend examples include anaemia, neutropenia, lymphopenia, Offering an HIV test to thrombocytopenia and diffuse hypergammaglobulinemia.
anyone with:• neutropenia Look for evidence of HIV: see guidance on assessment on • thrombocytopenia page 29, and also boxed information below.
• any other unexplained blood dyscrasia.
management/referral
as usual and arrange an HIV test if appropriate.
What to do if you suspect HIV infection may underlie the
If the problem is clinically minor (seborrhoeic dermatitis in a patient who had multidermatomal shingles two months ago), it may be reasonable to arrange an early review of the patient in order to give yourself time to collect your thoughts. But don't risk losing patients to follow-up. remember that resolution of the presenting problem does not mean that HIV has been ruled out.
• Enquire about weight loss, sweats, diarrhoea.
• Examine the patient for other signs of immunosuppression (mouth, skin and nodes, see pages 35-37).
• Review the records for evidence of HIV-associated problems in the last three years (see list, pages 30-38).
• Discuss the possibility of HIV with the patient to consider their risk.
For many GPs raising the subject of HIV with the patient is difficult. For more details on risk assessment, see page 45 and for suggested phrases for raising the question of an HIV test, see pages 47-49.
• Decide on priorities: is urgent assessment by a specialist required or can an HIV test be offered? For more on risk
assessment see
If the clinical picture is strongly suggestive of HIV, an apparent absence of risk of infection should not deter you from offering a test.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
case study
late diagnosis of HIV and tuberculosis
with a member of the HIV team she Jemi is a 26-year-old woman who came to reluctantly agreed to an HIV test, which was the UK from Sierra Leone two years ago. She positive. She was eventually diagnosed with saw her GP with a six-week tuberculosis following history of fevers, sputum culture.
intermittent cough and The history that emerged complaining of non- cervical lymphadenopathy. when she felt better was specific fatigue/malaise Nine months previously she that she had been feeling ‘ill' for at least eight or nine had attended her GP with for at least six to eight fatigue and was found to months, for which the full weeks, and had had have mild anaemia. Now blood count had been intermittent fevers (and she was prescribed the only investigation. some night sweats) for three Penicillin V, which alleviated She might not have months. She had been her symptoms for a few agreed to an HIV test at complaining of non-specific days. A week later she that time, but an earlier fatigue/malaise for at least presented again with rigors, eight or nine months, for diagnosis might have night sweats and weight which the full blood count enabled her to avoid loss. She was admitted to had been the only hospital for investigation of investigation. She might not pyrexia of unknown origin have agreed to an HIV test with malaria at the top of the differential at that time, but an earlier diagnosis might have enabled her to avoid hospitalisation.
She was found to have non-tender ‘rubbery' lymphadenopathy in her axilliary, inguinal, supraclavicular and cervical areas. • The UK National Guidelines for HIV Testing On admission she also had a fever of 39.4ºC 2008 recommend HIV testing for patients and a tachycardia. She was hypotensive, had presenting with pyrexia of unknown origin 2-3cms hepatomegaly and otherwise no and weight loss.
focal signs in her chest, abdomen or CNS.
• HIV should be considered in people from She was treated with multiple antibiotics areas of high HIV prevalence, regardless of but did not improve. Following discussion their presentation.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
case study
a delayed diagnosis
without further complication.
Ganesh is a 49-year-old divorced university The only recorded social history was that lecturer. He attended his GP some months he was divorced and smoked 20 cigarettes ago with diarrhoea and weight loss. Stool daily. He was not embarrassed to tell the culture/microscopy revealed no apparent doctors that he had sex with other men, but pathogen and there was little response to nobody had ever asked him. He was not anti-diarrhoeal medication. He was referred surprised by the subsequent HIV diagnosis. to the local hospital where he was seen and His CD4 count was 49 cells/μl and he has placed on the waiting list for both upper GI done well since starting combination endoscopy and a flexible sigmoidoscopy. This was performed four months after the original referral letter, his symptoms having continued and his overall weight loss being • The UK National Guidelines for HIV Testing some 10 per cent of his original weight. 2008 recommend testing for patients After the procedure he had to stay in presenting with persistent unresolved hospital for two nights as he appeared to diarrhoea and weight loss.
have developed an aspiration pneumonia. • If the symptoms could indicate HIV Broad-spectrum antibiotic treatment did very infection it is important to offer an HIV test little and he was re-admitted four days later. even if a risk assessment has not been Bronchoscopy confirmed a diagnosis of PCP, done, or no risk behaviour has been for which he was admitted and treated disclosed by the patient.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
case study
a ‘low-risk' man
a worsening of his cough and extreme Russel is a 33-year-old of UK origin who fatigue. He had marked dyspnoea on first presented to the practice nurse during a exertion. Two days later his girlfriend took new patient medical fol owing a house him to casualty. By this time his dyspnoea move. He lived with his girlfriend of eight had worsened, his weight loss continued and years. At registration he complained of a he had a dry cough. He was found to be rash on his face. This was red, dry and flaky tachypnoeic and hypoxic. His CXR showed and affected his forehead patchy shadowing. The and his naso-labial folds. He With no apparent risk medical team felt he was given a topical factors to suggest a probably had Pneumocystis significant probability of pneumonia (PCP). This was later confirmed on HIV infection, and with Twelve months later he bronchoscopy. Russell such an insidious onset, returned to the practice and tested positive for HIV and the diagnosis eluded saw a locum GP following his CD4 count was only 10 many practitioners until three days of non-specific cells/μl. Following the Russell was quite abdominal pain and fever. successful treatment of his He returned again to the PCP and initiation of practice after 10 days with a antiretroviral therapy, he dry cough, fatigue and lethargy. He was returned to work and remains well.
given a broad-spectrum antibiotic but 14 With no apparent risk factors to suggest days later was worse, and had developed a a significant probability of HIV infection, and generalised maculopapular rash. The facial with such an insidious onset, the diagnosis rash had returned, since he had run out of eluded many practitioners until Russel was cream. He had lost 4kg of weight.
quite seriously il . It is probable that he Frustrated at being off work for so long, acquired HIV through a sexual contact many he requested a referral to the local hospital years previously when he was travel ing in where he was seen by a consultant physician Thailand and South East Asia in his student three weeks later. Tests carried out by the GP years.
in advance revealed a slight thrombocytopenia, mild elevation of his liver transaminases and a raised ESR. A chest • Some people with HIV have no obvious X-ray was reported as normal. Russell was risk factors for HIV infection.
asked if he had ever injected drugs and • HIV infection can often exacerbate stated that he had not done so. Serology for common skin conditions.
hepatitis B was negative. Physical • Consider PCP in patients with recent examination by the hospital consultant onset dyspnoea or where atypical or revealed no abnormalities and an ultrasound severe respiratory infection is possible.
of his liver was arranged.
• Don't forget to ask about travel to areas Another three weeks passed, with no of high HIV prevalence when taking a scan appointment arriving. Russell reported HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
case study
a newly registered african woman
an HIV test was done, and the patient Haruzivi is a 34-year-old Zimbabwean carer agreed. The result was positive, information who had just registered with her GP. Her new which Haruzivi took surprisingly well.
patient check noted that her child had died in Haruzivi was referred to the HIV clinic and Zimbabwe before she came to this country soon after commenced on ART. Currently, three years ago. When her records came she is quite well and continues to work. On they showed she had had a previous several occasions since her diagnosis she abnormal smear (CIN 1).
has thanked her GP for suggesting the HIV Haruzivi attended the surgery because of test. She had felt she was not at risk and is recurrent genital itching. She described her glad that she had the test before she became current health as good. On examination she seriously unwell.
was found to have genital herpes and Molluscum contagiosum. The GP also found cervical lymphadenopathy. She had no other • HIV should be considered in people from rashes and no oral conditions suggestive of areas of high HIV prevalence, regardless of HIV. On further questioning her GP their presentation.
ascertained she had no history of previous • The presence of conditions that may be sexually transmitted infections and had never HIV-related can be used to initiate been tested for HIV. The GP suggested that discussions about HIV testing.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
HIV testing in primary care
reducing the amount of undiagnosed HIV in the UK is a priority. Individuals who know they are infected with HIV have significant advantages over those who are infected but unaware of this. They will:• benefit from current treatments resulting in an improved prognosis See the UK National • have information which may enable them to Guidelines for HIV Testing avoid passing on the virus 2008 at www.bhiva.org, www.bashh.org and • become less infectious once on arT • have the opportunity to reflect and plan ahead.
1. The practicalities
What is the HIV test?
See page 26 for
There are different types of HIV test. The most commonly used modern information on
tests detect both HIV antibodies and antigens. It is important to primary HIV
remember that occasionally the test may not become positive until one month or more after the person has become infected (the window period) and current guidance recommends a repeat test at three months after the most recent risk.
In primary HIV infection, an HIV test will usually be positive but may be For the types of
negative or equivocal.
HIV test including
rapid point-of-care tests (POCTs) are useful in many situations where an instant result is needed and you may decide that they are appropriate pages 15-16
for use in your practice if you and your staff feel confident to deal with a reactive result and can incorporate their use into your normal working routines. However, POCTs can have some disadvantages. GPs will often want to take USEFUL INFO
a full blood sample anyway for other Recent joint guidelines provide more reasons such as sickle cell screening, lipids detailed advice for doctors (Association of or viral hepatitis. also, the very short interval British Insurers & British Medical between testing and result may not be ideal Association (2010) Medical information and if you prefer to have time to think and plan insurance: joint guidelines from the British before giving a positive result. If considering Medical Association and the Association of POCTs, you should seek expert advice on British Insurers). Insurers should only ask their selection and use.
whether the applicant has tested positive for HIV. For updated guidance on HIV testing and insurance reports
confidentiality from the GMC, see GPs should not allow insurance concerns Confidentiality (2009) at www.gmc-uk.org – to compromise patient care: if an HIV test is GPs should be guided by clinical need appropriate, it should be offered. In the past above al other considerations.
there has been a reluctance to use HIV tests as a diagnostic tool in primary care. HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
This has been partly due to concerns that a patient or doctor may have to declare an HIV test (regardless of the result) on an insurance application or medical report form. However, as long ago as 1994, the association of British Insurers stated that a negative HIV test should not affect the application.
Laboratory support
The lab will need a clotted sample. Some smaller hospital laboratories
only run HIV tests on certain days. Larger hospitals have several runs on
a daily basis and have access to POCTs. Phone the lab to check:
• when HIV tests are processed
• when the results will be available
• what their procedure will be if they find an apparent positive.
Typically a lab will call when they find a positive result, and request a repeat sample.
Links with specialist HIV treatment centre(s)
The best time to find out about local HIV treatment centres and to
establish links with them is before you have a patient who tests positive.
This will ensure that clear referral pathways are in place, including details
of who to contact if a patient needs to be seen urgently by a specialist.
Computer and paper systems to support HIV testing
See page 85 for discussion of systems and record keeping.
2. When should an HIV test be offered?
There are a number of circumstances in which it is appropriate to conduct
an HIV test in primary care:
• patient request
• opportunistic testing – when an HIV test is offered to someone who
• diagnostic testing – when an HIV test is done because someone has an indicator condition, or symptoms or signs of HIV infection • screening – for example antenatal screening, or routine offering of the test to someone who has had a diagnosis of an STI.
If the test is offered on a routine or opt-out basis, evidence suggests it makes offering the test easier as it is perceived as non-judgemental and it is more likely to be accepted.
The patient who requests an HIV test
Patients requesting an HIV test will have a reason. you may choose to be
reassuring but avoid discouraging patients from testing and take care
before declining to test.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Be flexible: some people with HIV may have no apparent risk. Patients may or may not be prepared to discuss their risks with you. you do not window period and
always need to know what risk there was, as long as the patient different types of
understands the significance of the window period and what constitutes HIV test see pages
risk. If doubts remain, arrange a second test at the appropriate time.
The patient may have an identified risk
as HIV infection may be asymptomatic for some time, the only hope of
improving primary care detection rates in this group is if clinicians are
willing and able to discuss risk of HIV and offer tests as appropriate. risk
of HIV can be identified through drug and sexual history taking for the
purposes of health promotion.
The following should be offered a test if they have never been tested, or if they have been at risk since their last test. Those who:• have a current or former sexual partner who is infected with HIV, or from an area with a high prevalence of HIV or who was an injecting drug user • are men who have had sex with another man • are female sexual contacts of men who have sex with men• are from an area with a high prevalence of HIV (although risk should be discussed without pre-judgement as many people in this group may be at no risk) • have had multiple sexual partners• have a history of sexually transmitted infection• have a history of injecting drug use• have been raped (although in an acute situation this is best managed by specialist services if the patient will attend) • have had blood transfusions, transplants or other risk prone procedures in countries without rigorous procedures for HIV screening • may have had an occupational exposure.
Careful condom use will have offered significant protection – this should be acknowledged, even if testing still goes ahead. Be ready to test anyone who requests an HIV test after their history has been taken, even if they have not indicated a specific risk to you.
IMPORTANT!
Make sure all pregnant women are offered and
recommended an HIV test. Interventions can
reduce the risk of mother-to-child transmission
from over 20 per cent to less than 1 per cent.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
The patient may have symptoms or signs suggestive of HIV
disease

For clinical
See pages 27-36 for clinical diagnosis and pages 47-49 for diagnosis see box
communication strategies in this context.
on page 29
The patient may be in a group offered screening tests for
HIV

For preventing
Screening will sometimes be offered in a specialist setting, and sometimes in primary care. For example: transmission see
• women in antenatal care, in order to prevent mother-to-child • those found to have conditions which may be associated with HIV (such as TB, lymphoma, hepatitis B or C, syphilis or other STIs).
It is important that the value of the HIV test is explained to the patient.
Areas in the UK with high local diagnosed HIV prevalence
(greater than two in 1,000)
Based on cost-effectiveness data from the US, the UK National
See Time to test for Guidelines for HIV Testing 2008 recommend that HIV testing should be HIV: expanded considered for all new patient registrations in primary care and routine healthcare and medical admissions in areas of local diagnosed HIV prevalence equal to community HIV or greater than two in 1,000. The results of UK pilot studies of this testing in England approach have now been published by the Health Protection agency and at www.hpa.org.uk the data support the recommendation. However, its wide-scale implementation will depend on local commissioning priorities and appropriate resourcing, training and support for practices.
Opportunities to raise the subject of an HIV test may arise:
• before a sexual history has been taken – perhaps in a contraception or cervical screening consultation • once a sexual history has been taken – perhaps the patient has identified risk factors • when a history of injecting drug use has been identified• in a new patient check during a discussion about sexual health• if your practice is in an area of high local HIV prevalence.
remember to emphasise the benefits of earlier HIV diagnosis.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Useful phrases to help bring up HIV testing
(With thanks to Sexual Health in Practice (SHIP), Illnesses like this are usually
caused by viruses, for example the
glandular fever or flu virus. Some

If the patient has signs
quite rare viruses can also be a
and symptoms of
cause, and it is important that I
infection V
don't miss them if they occur. I
don't know if you are at risk, but HIV
is one of these.

The problems that you have had
recently are quite common, and
usually minor. However, very
occasionally they can give a clue
that your immune system is not

I don't know if you are at risk of HIV,
working as well as it should.
but this is one condition that can
affect the immune system. Could I
ask you some questions to see if
you could be at risk?

From what you tell me you are quite
unlikely to have HIV but I think it
would be wise to do a test anyway
so that we can be sure. Is that OK?

All pregnant women are
automatically offered a test for
syphilis, hepatitis B, HIV and rubella

If the patient is in
– however we think it's better to
a group offered
have this information before you get
screening, or a group at
pregnant. Would you like a test?
higher risk of HIV
infection
V
Current advice is that everyone who
[To a patient with an STI, eg herpes
has injected drugs in the past
or warts] I would always
should be offered a test for HIV,
recommend chlamydia and HIV
because this condition responds so
tests, as you may have been at risk
well to treatment. Have you ever
of these infections too – and they
considered having a test?
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
If the patient is in
[To a male patient] Because two of
a group offered
your partners in the last year have
screening, or a group
been male, it is possible that you
at higher risk of HIV
are at higher risk of HIV. Have you
infection (cont'd) V
ever considered having an HIV test?
We find that quite a lot of young
men are at risk of having sexual

OK, so you'd like a test for
health problems. Could I ask you a
chlamydia. Would you like an HIV
few questions to see if you are at
test too?
There is a lot of HIV in your home
So you had a negative test for HIV a
country, I think. Do you know
year ago – is there any reason you
anyone who is affected? Have you
wouldn't want another check now?
ever had a test?
as part of general
We are trying to do a lot more HIV
holistic care and
testing because undiagnosed HIV
‘good doctoring' V
can do a lot of damage and we
know the infection responds so well
to treatment.

There is really quite a lot of
undiagnosed HIV in this area so we
are trying to increase our testing
rates as people do much better if

We include an HIV test in our new
they know they have it.
patient check for everyone because
we're in a part of the country where
there are higher than average levels
of HIV and we wouldn't want to miss
anyone. Is that OK?

HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
as part of general holistic care (cont'd) X
But doctor – do you really think I
need to have an HIV test?

Well I don't think it's my job to
dissuade anyone from having an HIV
test at present. Currently doctors
are doing too few tests, not too
many. I would say: if in doubt, test.

3. The pre-test discussion
The UK National Guidelines for HIV Testing 2008 state that the primary purpose of pre-test discussion is to establish informed consent to the HIV test and that lengthy pre-test counsel ing is not required unless a patient requests or needs it. The time a discussion takes is extremely variable, but in a wel -informed, reasonably low risk person it may take just a few minutes.
Essential elements of the pre-test discussion
the benefits of HIV testing
If the patient gets a negative HIV test result:
• they have the reassurance that they do not have HIV
• they can continue to take steps to avoid HIV
• their current condition can be treated without being affected by HIV.
If the patient gets a positive HIV test result: • there are effective treatments that will stop them getting ill with HIV-related diseases The essential aspects that • they can take steps to avoid passing it on to their sexual need to be covered in the pre-test discussion are: • treatment for any other conditions can be adjusted, if • the benefits of testing for necessary, to make sure that treatment is most effective • people with HIV can have healthy children if they know • details of how the result their HIV status early on in pregnancy will be given.
• they will have more control over who to tell, and when, than if they found out while very ill with HIV infection.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
check whether you have their contact details
record contact details, and check their preferred method of contact and
any possible problems with leaving messages or talking. you will be glad
of this if the patient fails to attend for a result that turned out to be
positive.
arrange an appointment for the result to be given
Try to ensure that you are not going to give a result at a bad time – for example, a Friday evening surgery. a good rule is to arrange to give the Standards for the management of result face to face. If the result is negative, you can always ring them sexually transmitted instead if that is more convenient and saves them a repeat visit. nurses infections (STIs) at may also give negative HIV results on the phone. If you arrange to give the www.bashh.org and result by phone, and then later ask them to come to the surgery instead because the result is positive, this can create unnecessary anxiety.
a ‘no news is good news' policy is not considered good practice for HIV and STI test results, according to the British association for Sexual Health and HIV.
check whether the patient has given clear consent to HIV
(or other) tests
Informed consent must be obtained before any test. ask them directly if
they agree to the HIV test. Written consent is not required.
Other areas sometimes covered in a pre-test discussion
Given here is a breakdown of further issues that might be covered in a
See HIV testing
aide-memoire on
pre-test discussion with a patient who needs or requests it. not all areas will need to be covered with all patients. a checklist is given on page 90 which can be used as an aide-memoire by the GP or practice nurse.
i) check the patient's understanding of HIV
assess their understanding of different transmission routes and of the
difference between HIV and aIDS. Some patients believe that if they have
had any blood tests in the past, they will automatically have been tested
for HIV. also, the patient should understand the significance of the
window period and that a repeat test may be needed.
ii) discuss risk to date
Knowing the nature of the risk enables you to tailor advice on risk
reduction, and knowing the timing of risk(s) is important because of the
window period (see pages 15-16). If doubt about the window period
remains, simply arrange a second test in three months.
If the patient does not wish to discuss their risk, but wishes to go ahead with a test, they should be able to do so as long as the benefits of discussing risk have been mentioned.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
See page 45 for risks that may be discussed. If the patient is unwilling to go into detail, it may be best simply to address the issues on the HIV aide-memoire (page 90) in order to maintain the doctor-patient relationship.
iii) discuss future risk and risk reduction
This may be the first opportunity that a patient has had to discuss risk
reduction. It is best to discuss safer sexual practices and safer injecting
See more on the
practices before the test, not least because risks may be taken before the timing of risks on
patient is next seen. If a repeat test is to be arranged, emphasise that if HIV is transmitted between now and the next test, it may not show up in that result. also, if the patient has recently been exposed, and therefore possibly recently infected, they may well be highly infectious so they should be encouraged to consider this and practice risk reduction before the repeat test.
iv) discuss the implications of a positive test
How is the patient likely to react if the result is positive? What would their
main concerns be if they tested positive? Who would they tell? Who
would they not tell? What will be the reactions be of those they might tell?
What might be the implications for their partner? For their work?
Bear in mind that a smal minority of patients may tel you that a positive HIV test result would be too much to bear and they might self-harm in some way. It is important to use your judgement about whether a test in general practice under these circumstances is appropriate, or if the patient may benefit from the additional support that a test in GUm could of er.
v) explain confidentiality
explain that a positive test result will need to be recorded in their medical
records so that their healthcare remains safe and appropriate. reassure
the patient that such records are stored securely and are only available to
the relevant healthcare professionals.
If the patient has concerns about how HIV testing might affect insurance applications:• explain that a positive result would have to be disclosed to insurance companies if requested • emphasise that negative tests do not have to be disclosed.
vi) discuss how they will cope with the wait
ask the patient to consider who knows they are having a test, and who it
is safe to tell. advise the patient not to drink alcohol or take recreational
drugs on the day of the result. Consider whether there is any written
information that should be given to the patient.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
vii) consider if the test is best conducted in primary care
In people with psychological or emotional problems, or those with
additional counselling needs, a referral to GUm services for testing may
be appropriate. This should be balanced against the benefits of having
a test conducted in familiar surroundings and by a clinician known to
the patient.
viii) consider whether other tests are appropriate
It may be appropriate to request other tests at the same time as HIV.
For example:
• if the risk is considered to be due to needle sharing, talk to the patient
about testing for hepatitis B and C • if the risk is unprotected sexual intercourse – particularly if the risk appears high – then you may wish to discuss tests for other STIs such as chlamydia or hepatitis B.
There is a growing trend for specialist clinics to offer routine tests for hepatitis B and C alongside HIV. Consider the need for immunisation against hepatitis B.
ix) consider whether repeat tests are required
For more detail on
the window period
ensure the patient understands if they are going to need a repeat test see pages 15-16
(to cover the window period) before HIV infection can be ruled out.
x) check if the patient has a supply of appropriate condoms and
lubricant
Some practices can provide condoms and lubricant, but if not,
signposting to GUm, contraceptive services or gay men's health
organisations where free condoms and lubricant are available is helpful.
4. Giving the result
• If the result is negative, you need to consider whether the patient
needs a further test because of the window period.
• If the result is positive, there are many things you need to consider before the patient attends.
Preparing to give a positive result
you will have time to collect your thoughts and seek advice, because the lab is likely to phone the result through and ask for a repeat sample.
When giving a negative result, don't forget to reinforce advice about minimising risk, • you already have skills in discussing very difficult things if appropriate.
• the patient chose you to do their test, so they chose you to give them the result.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
review the notes from the consultation when you took the test. If the pre-test discussion was brief, there may not be very much information, so prepare to ask the patient to consider the fol owing:• what is their main concern should the test be positive?• who knows they were being tested? • where do they get support?• is there a partner whose needs you should discuss with the patient? (Formal partner notification should be addressed by the HIV clinic.) Consider referral arrangements:• the patient will need to be referred to a specialist HIV clinic for See ‘the newly
assessment within two weeks of testing positive so an appointment diagnosed patient'
can be made in advance. Patients may have their own preferences for on page 58
treatment centres so should be involved in this decision wherever possible • have phone numbers of support organisations and relevant literature When the patient attends
Give the result soon after the patient is in the room and has sat down.
Delaying disclosure can heighten anxiety. This allows you more time to
attend to and deal with the patient's reactions. Some patients are
expecting a positive result and may be quite calm. Indeed, some may
have already come to terms with being positive. a calm exterior can also
mask a sense of shock.
In the case of a positive result, listen carefully and make the discussion focused and tailored to the individual.
you should emphasise the positive aspects: patients are better off knowing that they have HIV.
When the consultation is coming to an end:• give the patient the details of any appointment that you have arranged• remember that risk reduction advice to protect partners will need to be addressed at some point, but this may be hard for the patient to take in at this consultation • arrange to follow up the patient within a few days as they may well have additional questions and it will give you the opportunity to check that referral to the specialist service has been actioned.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
case study
an opportunity to test for HIV
to HIV through several ‘casual' sexual Pascal, aged 26, attended the practice nurse contacts in years gone by. Pascal explained for a new patient check. He was an that he had always meant to have a test for accountant, and generally fit and well with no HIV, but never got round to it. He had also significant past medical history. The practice discussed it with his partner in the past, but encouraged sexual health more recently the subject promotion, and the nurse The HIV tests were had been forgotten.
raised the subject after After discussion it was negative. They were very other aspects of the check agreed that Pascal would grateful to the nurse for were complete.
suggest to his partner that having dealt with an She asked him if it was he also registered ‘as it issue that had been a okay if she asked questions seems a really nice suppressed but niggling to see if he could be at risk practice'. The nurse agreed of any sexual health she would be happy to problems. He agreed, but arrange an HIV test for both seemed to become a bit guarded. The nurse of them. In due course, both attended. The took a partner history according to her HIV tests were negative. They were very routine, avoiding assumptions. The patient grateful to the nurse for having dealt with an opened up and relaxed, and shortly issue that had been a suppressed but explained that he wasn't living alone as he niggling worry.
had told her, but was gay and living with his partner of three years. He felt this relationship was mutually monogamous, but • Offering the HIV test can allay anxiety even he had had several partners prior to this. She where the result is negative.
asked about condom use and established • A negative result is a good opportunity for that he had had significant risk of exposure sexual health promotion.
HIV In PrImary Care 2nd edition How to diagnose HIV in primary care
Section 2
Summary: how to improve HIV detection in your practice
familiarise gps and practice nurses in the team with:
• the more HIV-specific aspects of primary HIV infection, and be ready to ask about
them in patients with a ‘glandular fever-like' illness (pages 26-27) • those urgent conditions that may present in patients whose HIV infection remains undiagnosed, most importantly PCP (pages 29-30) • those indicator conditions that are associated with HIV infection (pages 29-38), especially if they have had: – more than one in the last two to three years; or – an unusually difficult to treat or severe form of these conditions • risk factors for HIV which should prompt an offer of an HIV test (see page 45).
Print off the clinical indicator conditions table from the 2008 HIV testing guidelines (at the back of this booklet) and put it up in all consulting rooms.
Plan and practise strategies for discussing HIV with patients in different clinical circumstances.
Take steps to incorporate HIV testing into the health promotion work of the practice nurse team.
Consider including the HIV test in all new patient registrations if local diagnosed HIV prevalence is equal to or greater than two in 1,000.
Arrange a practice development session on HIV and STI testing – your local GUM service could help, or look at online learning options such as e-GP.
HIV In PrImary Care 2nd edition Section 2
How to diagnose HIV in primary care
HIV In PrImary Care 2nd edition In tHIS Se 3
Patients with HIV Health promotion, screening and immunisation for people with HIV 59 Sexual and reproductive health Managing HIV-related problems Caring for people on antiretroviral therapy (ART) Additional treatments for those with immunosuppression The patient who wil not attend for specialist care The dying patient HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
Clinical care for HIV is increasingly managed as a chronic disease, with many individuals surviving for long periods. This, along with other changes in health policy, is shifting the emphasis of care towards partnership between specialist centres and primary care.
Patients with HIV
1. The newly diagnosed patient
Unfortunately, HIV infection is still a stigmatised condition and thus telling
friends, family or colleagues is never easy. Some people will not be
prepared to absorb fully the news of a positive test result. even if they
received in-depth pre-test discussion, some may need considerable
support over time.
a significant number of women with HIV have been identified through antenatal screening. Such women may be facing a truly chal enging range of issues: a newly diagnosed and serious medical condition, starting life-long medication, a pregnancy and whether to continue with it, the possibility that existing children and/or their partner are infected, all at the same time.
2. The patient who informs you they have HIV
a patient may inform their GP or practice nurse that they have HIV. many
patients with long-standing HIV infection can be considered ‘expert
patients' and some of these may be proactive in involving you in their
general medical care.
Others may be more anxious about divulging this information. It may take some time before a patient with HIV chooses to disclose this to their GP, or they may find that il ness forces the decision. They may require reassurance about the confidentiality of their records and the attitudes of practice staff who wil need to know about their HIV status. Communication with the specialist clinic should be established as soon as possible.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
Health promotion, screening and immunisation for
people with HIV
1. Cardiovascular disease prevention
research indicates that people with HIV are at higher risk from
cardiovascular disease, although the mechanism of action is unclear. This
appears to be particularly true for those who are not yet on antiretroviral
therapy (arT). In addition, dyslipidemias and diabetes are associated with
arT (see arT side effects, page 71). effort should therefore be put into
promoting healthy diets, exercise, alcohol control, blood pressure checks
and smoking cessation. There are no recorded interactions between arT
and varenicline. If in doubt, however, seek expert advice.
2. Cervical screening
Women with HIV are more at risk from HPV-related disease, including cervical
See case study
cancer and warts. al women with HIV infection should have annual smears with more frequent fol ow-up and colposcopy if abnormalities are found.
3. Immunisation
The practice can and should play a key role in immunising patients who
See Department of have HIV. Current advice can be found in the BHIVA Guidelines for the Heath Immunisation against infectious immunization of HIV-infected adults (2008) which are very useful and diseases at practical for GPs. ‘The Green Book' (Department of Health: Immunisation against infectious disease) is also very helpful. It can be viewed online where it is updated regularly.
Individuals with HIV infection should not normal y receive BCG, cholera, or oral typhoid. Live oral polio (Sabin) immunisation should not be given due to the smal risk of contact with excreted live vaccine. al inactivated immunisations such as pertussis, diphtheria, tetanus, inactivated polio (Salk), typhoid, and meningitis C are safe. Specialist advice from the HIV unit should be obtained where appropriate.
adults with HIV should be offered: See BHIVA (2008) Guidelines for the • influenza immunisation each year immunization of • hepatitis B testing and immunisation as appropriate HIV-infected adults • hepatitis a immunisation for men who have sex with men • pneumococcal vaccination• novel H1n1 (swine flu).
Specialist advice should be sought from the paediatric team about immunisation of children infected with HIV, and children of parents with HIV.
If a baby is born to a mother with HIV, transmitted infection will usually have been identified by eight weeks. Inactivated polio should be given if any family members are immunosuppressed, or if there is doubt about the baby's status.
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
4. Advice and immunisation for international travel
Hepatitis a and B vaccination should be offered as appropriate. It is
important to remember to check hepatitis B titres. For those who do not
respond to hepatitis B vaccination, specialist advice should USEFUL INFO
be sought. The BHIVa guidelines provide more detailed Some countries restrict entry for those with HIV. malaria prophylaxis is used, but interactions with arT can Patients should check occur. The antiretroviral, ritonavir, for example, can interact with with the relevant several antimalarials. Check on www.hiv-druginteractions.org embassy or embassies For patients with HIV travelling to areas where medical before planning their support may be difficult to obtain, GPs might supply a couple of courses of ciprofloxacin for travellers' diarrhoea, together www.aidsmap.com for with advice on hygiene and food preparation.
a list of these countries.
advice on safer sex and the avoidance of sexually transmitted infections may need to be reinforced.
case study
a case of missing smears?
vaccinated; she is HIV-negative.
Consuela is a 40-year-old woman from South In 2009 an unexpected hospital smear America who registered with the practice in result arrived at the practice showing severe 2004. She had moved to the UK some 13 squamous dyskaryosis present with features years previously and had been under the care suspicious of invasion; colposcopy was of another practice in the locality, but switched recommended. There had been no when she changed address. Consuela was symptoms. Within six weeks a radical already aware of her positive HIV status when hysterectomy had been performed with she registered, but did not disclose this to the lymph node dissection, although there was practice. Over the next two years she did not evidence of micro-invasion confirmed on attend the surgery very often and did not histology. Consuela is under the close respond to invitations for cervical screening. supervision of the gynaecologist and the The practice nurse had tried frequently to call specialist oncology unit. This year Consuela her in. On the phone on one occasion has had her first post-operative vaginal vault Consuela told the practice nurse that a smear smear which shows moderate squamous test had been done in a ‘clinic appointment' at dyskaryosis and it is likely that she will need the hospital. The nurse asked her to bring a chemotherapy. This is being planned.
copy of the result but this was not forthcoming.
In 2007 Consuela became pregnant and was duly referred to the antenatal unit at the • Women with HIV are at higher risk of same hospital where she was accessing her cervical cancer and should have annual HIV care. The pregnancy was uncomplicated screening tests.
and she delivered a girl by normal delivery. • Practices should liaise closely with HIV The baby has also since been registered with clinics to ensure the tests have been done the practice and she has been fully and results are available.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
Patients may also be offered a concise medical summary, including prescribed medication, in case of illness abroad. Some drugs, especially opiates, may need a licence from the Home Office. also, check the entry requirements for the country concerned to ensure they do not deny entry to those with HIV. a list can be found on the aidsmap website (see useful sources for patients in Quick reference on page 104).
Sexual and reproductive health
1. Sexual health advice
Healthcare workers need to be able to discuss sexual practices with
patients living with HIV. many people find it difficult to maintain safer sex, BASHH/BHIVA/FSRH (2008) UK so practitioners should be supportive and avoid criticism. Ideally, guidelines for the practices should provide condoms and (for anal sex) lubricant, but if not, management of signposting to services which provide free supplies is helpful.
sexual and Support from an expert counsellor or health adviser can be helpful in reproductive health addressing difficulties related to HIV disclosure, or with adopting or of people living with maintaining safer sexual behaviour to prevent onward HIV transmission HIV infection at and protect against the risk of STIs. expert advice may also be needed to address concerns about the (albeit unlikely) possibility of criminal prosecution if HIV transmission occurs.
It is helpful to make sure the patient with HIV is aware of the availability of post-exposure prophylaxis following sexual exposure (PePSe) should an HIV-negative partner be exposed to HIV (see page 81).
effective arT significantly reduces the risk of HIV transmission. Knowing this can reduce anxiety about the potential for accidental sexual transmission of HIV and may even be a factor in the decision to commence therapy. If the plasma viral load has been undetectable for more than six months, the risk of transmission is very low, although an undetermined residual risk of transmission is likely to exist. Condom use is recommended to reduce any residual risk; this is probably higher for anal than for vaginal or oral sex and increases with inadequate adherence to arT. The presence of STIs in either partner may have a dramatic effect on HIV transmission, so continued condom use is strongly recommended for those at continued risk, as are regular checks for other STIs.
even in couples where both partners have HIV, condom use is recommended if either is non-monogamous because of the potential risk of acquiring other STIs. Some STIs are harder to treat in those with HIV, while hepatitis C has become epidemic among men with HIV who have sex with men, between whom it is mostly sexual y transmitted. regular sexual health checks are therefore important. Superinfection with a drug-resistant strain of HIV (thus limiting future treatment options) is also possible, although this has been observed far less frequently than initial y anticipated.
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
2. Contraception
Contraceptive choice for HIV-infected women may be limited by
interactions with arT as the most commonly used arT combinations
include enzyme inducing drugs (the PIs and nnrTIs). Condoms are a
useful additional precaution against pregnancy where the efficacy of the
primary contraceptive choice may be reduced and remain the only method proven to reduce the risk of HIV transmission.
Reproductive Healthcare (2011) Clinical Guidance: Oral contraceptives and patches
Drug Interactions The combined oral contraceptive (COC), progestogen-only pil (POP) with Hormonal and hormonal patches may have reduced effectiveness with some Contraception at antiretroviral combinations (including most first-line combinations) due to enzyme induction, and expert advice should be sought. newer drugs such as maraviroc and etravirine do not interact with steroid hormones.
Long acting reversible contraception
The efficacy of the IUD, the IUS or depot medroxyprogesterone acetate
injections (at the usual intervals) does not appear to be affected by
enzyme inducing drugs. Implants, however, are potentially affected by
interactions with enzyme inducing HIV medications – there have been
cases of them failing in women on efavirenz – so switching to another
method, or using condoms in addition, is recommended.
Emergency contraception
The copper IUD is the most effective method and will not be affected by
drug interactions.
Doubling the dose of levonorgestrel (Levonelle) is generally advised for women on medication that interacts with progestogens (efavirenz, nevirapine, most protease inhibitors) although this is unlicensed. For women on other antiretrovirals this is not necessary; if in doubt a double dose may be appropriate as levonorgestrel side effects are few.
In the absence of data on its use by women taking enzyme inducing drugs, doubling the dose of ulipristal acetate (ellaOne) is not advised. Ulipristal acetate should not be used by women using enzyme inducing Healthcare (2009) drugs or who have stopped them within the last four weeks.
UK Medical The UK Medical Eligibility Criteria for Contraceptive Use provide Eligibility Criteria for detailed guidance on other factors which may influence contraceptive Contraceptive Use choice. Further information and up-to-date advice should always be sought from specialist services if there is uncertainty.
3. Fertility and assisted conception
Some couples with one partner infected with HIV will want to start a
family. This is an area which will be managed by specialists, but it is useful
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
to have some knowledge of the options to discuss with patients, should they raise the matter.
If the man has HIV infection, donor insemination is an option. For conception using the infected partner's sperm, the safest method is one cal ed ‘sperm washing'. This is very safe as long as the ‘washed' sperm is retested for HIV, and no transmissions have been documented. Further information should be sought from the HIV specialist if a couple are interested. Sperm washing may be funded by the nHS but is decided on a case-by-case basis and access may differ across different parts of the UK.
If it is the woman who has HIV infection, she can establish when she is ovulating using ovulation kits, and then artificially inseminate using semen from her partner. many successful pregnancies have resulted from this technique. This method is completely safe for the male partner.
Where the HIV-infected partner is on successful arT, a couple can also choose unprotected sexual intercourse which is timed to reduce the frequency of exposure (and thus the risk). If the man is on effective arT with an undetectable plasma viral load then the risk of transmission to a female partner is very low indeed. However, some men have detectable HIV in the semen even if it is undetectable in blood so the possibility of HIV infection cannot be entirely ruled out (see Sexual health advice above). It is important to counsel that very low risk does not mean zero risk. In the future pre-exposure prophylaxis (PreP) – where the HIV-negative partner takes arT for a short time before and after the unprotected intercourse – may be offered. There are a few cases where it has been used, but it is unlicensed and not routinely recommended at present. Trials to establish its efficacy are ongoing.
Sub-fertility should be addressed in the usual way, although HIV status should be made clear if the couple are referred.
4. Antenatal and postnatal care
many women with HIV are well and actively choose pregnancy. Some
may have an unplanned pregnancy that they choose to continue. Some
may have undergone the traumatic experience of discovering through
antenatal HIV testing that they were infected with HIV.
managing the pregnancy of a woman with HIV is strongly influenced by the need to prevent transmission to the baby. The risk of transmission can be reduced from around 20 per cent to under 1 per cent by the interventions given on page 20.
Support of bottle feeding
although there is evidence that arT reduces HIV viral load in breast milk,
the complete avoidance of breastfeeding for infants born to mothers with
HIV is still recommended, regardless of maternal disease status, viral load
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
or treatment. Support for bottle feeding should be offered and GPs may be able to prescribe infant formula milk if they feel it is appropriate.
This message may not be accepted by all mothers with HIV as, for some groups, breastfeeding has deep symbolic meaning. avoidance of breastfeeding may provoke enquiries about the reasons, leading to unwanted speculation about (or even disclosure of) the mother's HIV status. Where such concerns arise, advice and support should be available from midwives and others involved in care.
See BHIVA (2010) In the rare instances where a mother with HIV who is on effective arT Position statement with a repeatedly undetectable viral load chooses to breastfeed, the on infant feeding in British HIV association (BHIVa) and the Children's HIV association the UK at (CHIVa) no longer consider this as grounds for automatic referral to child www.bhiva.org or www.chiva.org.uk protection teams. However, intensive support and monitoring of mother and baby are recommended.
Asylum seekers
asylum seekers identified as HIV-positive (commonly through antenatal
screening) face particular financial difficulties. asylum support regulations
allow a payment of £3 to be made for children up to three (£5 for under-
ones) who are being supported by the UK Border agency to help with the
purchase of healthy foods. Pregnant women who are being supported by
the UK Border agency can also receive £3 a week under this scheme for
the duration of their pregnancy.
mental health problems are more common in people with HIV than in the general population. This is probably for two reasons. Firstly, those with pre-existing mental health problems are often more vulnerable and may have been prone to engaging in high-risk sex or injecting drugs in the past. Secondly, those diagnosed with HIV still face stigma, isolation and discrimination, all of which may make them more likely to become depressed or anxious.
many of those diagnosed with HIV in the 1980s and 90s stopped work and expected to become more unwell and die. While they later benefitted from improved treatments, which dramatically extended their prognosis, many had given up careers, cashed in pensions and life assurance policies and, after years out of the workplace, now face unemployment, dependence on state benefits and chronic ill-health. They may have experienced previous multiple bereavements and be vulnerable to depression. In general, HIV services in larger urban areas have access to psychiatrists and psychologists who specialise in this area. For the GP, management of mental health problems should be as normal.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
case study
a long-term survivor
1980s losing many friends and his partner to Andy is a 53-year-old gay man who has been AIDS. His family are aware of his HIV living with HIV since 1989. He has a previous diagnosis, but live a long way from him; he diagnosis of PCP and CMV retinitis and is has few friends and is very isolated due to visually impaired from this. He had a his chronic ill health and inability to work. He successful career, but when he became has had several significant episodes of unwell with AIDS he gave up depression since being his job and has not worked diagnosed with HIV. He feels since. He has a long challenge on many quite bleak and negative about antiretroviral history and has his future and his depression levels to his GP, suffered from many side-effects responds in part to SSRIs. with whom he has a over the years including renal He has made attempts to get good relationship stones and renal impairment back into employment, but is and whom he sees from indinavir, marked hampered by his poor vision lipoatrophy and lipodystrophy, and lack of work throughout which he found very the1990s. He presents a stigmatising, and problematic GI side-effects challenge on many levels to his GP, with which he has to manage symptomatically. He whom he has a good relationship and whom is currently stable on a complex ART regimen he sees frequently.
with an undetectable viral load and a CD4 count of 367/μl. He has multiple drug resistance because of his long antiretroviral • The mental health problems experienced history and has limited antiviral options at by people with HIV are similar to those present. He is also on medication for raised seen in people coping with a range of cholesterol and hypertension, and he has chronic conditions or disabilities.
impaired glucose tolerance. He is therefore • Management of mental health problems is taking an increasing list of non-HIV as normal in general practice, with the medication as well.
proviso that prescribed medications need He suffered multiple bereavements in the to be checked for interactions with ART.
remember that in your practice population, some people with mental health problems may be at increased risk from HIV and may not have been offered testing. Consider taking the opportunity in a review consultation to discuss this with them.
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
Managing HIV-related problems
1. The GP's role
In many ways, looking after someone with HIV is no dif erent from looking after those with other chronic conditions. The specialist centres are Standards for HIV responsible for initiating and monitoring arT and they remain responsible Clinical Care at for prescribing it. The role of the GP may vary depending upon the health of the patient. In addition, the relationship the GP has with the patient, and the relationship between the patient and their specialist team, wil af ect how primary care is used. For many health problems, al that is needed is advice, reassurance or simple treatment. nevertheless, there are times when immediate referral for assessment is likely to be appropriate.
It is important for GPs to have active communication with specialist HIV clinics. They should expect to be written to regularly, and should be prepared to notify specialists in return if there are significant changes in the patient's management or circumstances. It is also good practice to copy the HIV specialist into letters to/from other specialties as appropriate. Internal referrals from the HIV specialists should also be copied to the GP so that all clinicians are kept abreast of developments.
2. Health problems
Physical problems caused by HIV infection are significantly less common
in the diagnosed patient now that arT is widely used. a patient with HIV
See side effects of
who presents with symptoms might have: ART pages 71-74
• problems which relate to HIV disease (check the most recent CD4 • side effects of arT• an unconnected problem.
you may be able to take the first steps to distinguish which of these is the case. a recent CD4 count that is comfortably above 200 cel s/μl makes HIV-related problems less likely. Check which antiretrovirals the patient is on, and check for side ef ects in the BnF section 5.3 and also on page 92.
3. Conditions that require urgent referral
Serious conditions due to HIV disease affect patients with CD4 counts
For serious
below 200 cells/μl (except TB, see page 31).
conditions
associated with
Symptoms that require careful assessment include: HIV see pages
• respiratory• visual (even if apparently minor, such as floaters)• progressive or acute neurological problems.
Side effects of arT are sometimes serious or even life-threatening – check which medication the patient is on.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
4. Commoner conditions
many HIV-related problems are also common in patients who do not have
HIV such as shingles and seborrhoeic dermatitis. management of such
For commoner
conditions at a
conditions is generally the same and the GP is likely to be familiar with glance see pages
treatments. However, the immunosuppressed patient may require longer treatment than other patients.
5. Hepatitis B or C co-infection
Hepatitis B is common in those at risk from HIV. Chronic carriage is more
frequent and may need treatment and monitoring in specialist clinics.
Hepatitis C was originally seen in those who were infected by shared Guidelines for the needle use or contaminated blood products, but in recent years there has management of been an epidemic of hepatitis C amongst HIV-positive men who have sex coinfection with with men (mSm). The route of transmission in most of these cases is HIV-1 and hepatitis B or C virus at unprotected sex rather than injecting drug use. most HIV centres perform routine annual screening for hepatitis C as it can often be asymptomatic.
The HIV specialist team will manage any co-infected patients, but the primary care team can assist with adherence support and other medications to alleviate side effects of treatment such as antidepressants or sleeping tablets for those taking interferon/ribavarin for hepatitis C.
6. Managing patients with multiple co-morbidities
In general those infected with HIV have a higher risk of developing
diseases associated with ageing, including cardiovascular disease (CVD),
stroke, bone disease, chronic kidney disease (CKD) and a decline in
cognitive function. The primary care team is well placed to manage and
monitor such complex co-morbidities, but this is dependent on having a
collaborative relationship with your patient and good communication with
specialists.
Caring for people on antiretroviral therapy
antiretroviral therapy (arT) has had an enormous impact on morbidity and mortality from HIV disease. your patient (particularly if recently infected) has a good chance of living with their HIV for decades.
The management of HIV infection is complex and is undertaken by the specialist team. Further information can be found on the BHIVa website.
For more, see BHIVA (2008) Guidelines for the treatment of HIV-1 infected adults with antiretroviral therapy at www.bhiva.org HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
1. How the drugs act
Entry inhibitors (EIs)
eIs prevent the viral membrane of HIV fusing with the target cell
membrane and entering the cell.
Nucleoside/tide reverse transcriptase inhibitors (NRTIs)
nrTIs inhibit the enzyme reverse transcriptase that is key to transcribing
the viral rna into proviral Dna.
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
nnrTIs also inhibit the enzyme reverse transcriptase.
Integrase inhibitors (IIs)
IIs block the action of integrase, a viral enzyme that inserts the viral
genome into the Dna of the host cell.
Protease inhibitors (PIs)
PIs inhibit the production of protease. Viral protease is needed to form
new mature virus particles.
figure 6 HIV lifecycle and sites of action of drugs in cd4 cell
key to drugS
eI entry inhibitors
rtI reverse transcriptase inhibitors

(nrtIs and nnrtIs)
pI protease inhibitors
The drugs act to block steps in viral replication HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
2. Drug combinations used in ART
HIV readily mutates in the process of replication. This means that
resistance to single anti-HIV drugs develops very readily. For this reason
For a list of drugs
drugs are generally used in combinations of three or more.
see page 91
For initial regimens, a combination of two nrTIs with one nnrTI – now combined in a single tablet taken once a day – is often used. However, some people may be taking two nrTIs and a protease inhibitor (PI) boosted with a small dose of ritonavir (another PI) while other patients may be taking drugs from several classes. The choice of regimen will depend upon the need to minimise side effects and long-term toxicity, while providing an effective combination likely to suppress the virus long-term and be convenient for the patient. There are trials now looking at ways to reduce the number of drugs while maintaining optimal treatment outcomes. PI monotherapy has been shown to be appropriate for some individuals who are stable with an undetectable viral load.
3. When to start antiretroviral therapy
HIV specialists wil take into account a number of factors when deciding
when to start arT, including the CD4 count and risk of disease progression.
The choice of drugs will be informed by:• knowledge of effectiveness of combination• likelihood of resistance developing to chosen drug• transmitted drug resistance (if there was evidence that the patient was infected by a strain of virus already showing resistance) • drug toxicity• pill burden• drug-drug interactions• and, increasingly, cost.
It may take some time for a drug regimen to be found that suits the patient. Because some drugs can have significant side effects, treatment centres tend to monitor patients more closely for the first six to eight weeks of therapy. The indications for commencing treatment and the recommended regimens have changed over time. national guidelines are regularly updated.
4. Monitoring progress
monitoring of arT is primarily by viral load (see page 18). The aim is to
reduce the viral load to undetectable levels, usually within three to six
months of starting therapy.
5. Drug resistance
resistance of the virus to arT is minimised if combination therapy is
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
maintained at therapeutic levels in the blood stream. any interference with its action (for example, through drug interactions) or with its administration (for example, through not adhering to prescribed regimens) can lead to resistance developing. Drug resistance, once established, is irreversible. Cross-resistance between classes of drugs means treatment choices are further limited.
Current guidelines recommend resistance testing at the time of diagnosis in order to check for transmitted drug resistant virus, as well as for those receiving arT in whom the viral load starts to rise. This allows the HIV-specialist to determine the most appropriate drug choice for the patient.
6. Adherence to antiretroviral therapy regimens
If people with hypertension miss their medication for a short period of
time, it will still be effective when they re-start. Unfortunately this is not
always the case with arT due to viral resistance. adherence to a long-term drug regimen is one of the biggest challenges to Adherence is essential those who live with HIV as well as to those who support them.
monitoring adherence is something the primary care team can do well. When the patient is seen, the GP or practice nurse should assess and monitor how they are coping with taking their medication and whether they are missing doses. Patients need to understand the reasons behind the requirement for optimal adherence as well as the possible consequences of missed doses. If they discontinue or repeatedly miss doses, try to explore the reasons for this.
Some once-a-day HIV combination therapies have a long half-life so there is some flexibility for stable patients with undetectable viral loads, meaning that timing does not have to be so strict. However, for these combinations missing doses altogether can lead to resistance and increases the risk of treatment failure.
The timing of the medication through the day may be complex, especially if medications for other conditions are included alongside the arT. a patient might be on one drug that must be taken some time before meals, but another that must be taken directly after. even without these practical complications, it is hard to sustain a regular regimen without losing motivation or even simply forgetting doses. In some areas HIV specialists can arrange adherence support.
7. Drug interactions
PIs and nnrTIs are the groups most affected by drug interactions, being
metabolised via the cytochrome P450 enzyme system in the liver. check for drug interactions at: These interactions can lead to both increased toxicity and decreased efficacy. Dietary substances, herbal remedies and recreational drugs can all interact significantly.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
For further information see www.hiv-druginteractions.org. This site is run by the University of Liverpool and includes information on interactions between all the arT drug classes and most commonly prescribed medications, as well as dietary substances (under herbals/supplements/vitamins) and recreational drugs (under illicit/recreational). There is an option to get individual queries answered by the team at Liverpool University. In some areas advice from specialist pharmacists linked to hospital HIV services is available.
8. ART side effects
While the benefits of arT are enormous, side effects are common and
some may be serious. The specialist unit will be monitoring patients for
For ART side
side effects and most of them will be managed there. However, you may effects at a glance
need to be aware of them in the event that an HIV patient attends general see page 92
practice in an emergency, or uses the out-of-hours service. as antiretrovirals should not be stopped without good reason, management should always be discussed with a specialist before action is taken.
Side effects are most common with the three older drug classes, nrTIs, nnrTIs and PIs. There is limited knowledge of the side effects of entry and integrase inhibitors at the time of writing as these are the newest classes of antiretrovirals. However, they appear to have a lower side effect profile than the other drugs.
For a full list of both serious and minor side effects, see the BnF section 5.3. See ‘Quick reference' page 91 to identify which group each drug is in and page 92 for a table of side effects by drug type.
Minor side effects
arT can cause a huge range of minor side effects, which are generally
listed in the BnF (section 5.3). The GP will often be able to manage minor side effects in the normal way. However, they should always check for www.bnf.org section 5.3 drug interactions (see page 70). Symptomatic treatment is given on pages 93-96 (a guide to managing HIV-related problems).
Serious or unusual side effects
Some of the more serious side effects may not be the type of problem
that GPs would normally consider could be due to medication. In
addition, some serious ‘unusual' side effects of arT can present in an
insidious way, leaving the GP at risk of overlooking their significance.
Hypersensitivity
Hypersensitivity can occur with all drugs to different degrees. abacavir
and nevirapine are more often associated with serious reactions.
abacavir. This is thought to occur in 8 per cent of those who take abacavir. most HIV centres now perform Human Leukocyte antigen (HLa) HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
testing as this can help identify those more at risk from this reaction. However, a negative test does not mean there is no risk, only that it is less likely. It usually occurs within first six weeks, but not exclusively and can be life-threatening. It typically causes fever or rash but may cause a range of non specific symptoms such as fever, vomiting or myalgia. Seek advice urgently if suspected.
nevirapine. Usually within the first four weeks, but not exclusively. Can be life-threatening. Typically causes rash and Stevens Johnson-type syndrome. This is more common at CD4 counts above 250 in women and 400 in men.
psychiatric problems
efavirenz is the drug most associated with this group of side ef ects and is
commonly used as part of arT regimes. nightmares, sleep disturbances,
mood changes, behaviour changes and vivid (life-like) dreams are common.
This is general y transient at the initiation of therapy but can be longstanding.
Hyperlipidaemia
The majority of arT drugs are implicated, with some less problematic
than others. Increases are most likely when PIs are boosted with ritonavir.
arT can raise cholesterol and triglyceride levels, sometimes to an alarming degree. Diet can control levels in some, but those with high levels are increasingly treated with statins (atorvastatin, pravastatin) and fibrates (bezafibrate). Care must be Consider hepatic metabolism taken when selecting such drugs due to interactions and interactions when selecting and hepatic metabolism. In particular, simvastatin, drugs, especially statins.
which is commonly prescribed in primary care, must be avoided in those on arT due to interactions. It is also CONTRAINDICATED with essential to pay attention to other traditional CVD risk antiretroviral therapy! factors such as hypertension and smoking. Specialists should monitor lipids routinely.
lipodystrophy and lipoatrophy
First described with PIs, but may be associated with most antiretrovirals.
Lipodystophy is a syndrome caused by arT in which there are changes
in the distribution of body fat. Some individuals experience a loss of
subcutaneous fat causing facial (particularly cheek and temple) thinning
and limb and buttock wasting, known as lipoatrophy. It is particularly
associated with nrTIs. Others develop central (truncal) adiposity with an
increase in intra-abdominal fat, buffalo hump and breast enlargement.
This is predominantly associated with PIs.
These two forms of lipodystrophy may co-exist and may also be associated with other metabolic abnormalities such as diabetes (due to insulin resistance) and hyperlipidaemia.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
although the drugs that cause it are now used less frequently in the UK, lipodystrophy/lipoatrophy may be one of the biggest fears of patients taking antiretroviral combinations. It can be stigmatising and distressing, often resulting in low self-esteem, isolation and depression. awareness of the possibility of lipodystrophy may be a reason for some patients avoiding medication, and for some it may significantly affect adherence. Treatment for this syndrome is still largely unsatisfactory. a number of specialist centres offer treatment with polylactic acid, a filling agent for facial wasting.
diabetes (type II)
Susceptibility to diabetes – probably through insulin resistance – is
associated with arT and this may be complicated if the patient is
For ART drugs by
class see page 91
overweight. It can be managed in the usual way, but monitoring and additional medication may induce ‘adherence fatigue' in some patients. This can impact on both HIV and diabetes. again, it is important to pay Left to right:1. Lipoatrophy. One of the biggest fears of patients taking ART, this syndrome may also be associated with metabolic abnormalities such as diabetes and hyperlipidaemia.
2. Lipodystrophy. A syndrome probably caused by ART and characterised by redistribution ofbody fat.
eDIcAl IlluSTRATIo HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
attention to other CVD risk factors in such patients. Diabetes may be associated with lipodystrophy (see above), but can also occur in patients on arT who do not have obvious lipodystrophy.
renal problems
Tenofovir can be associated with a decline in renal function. This can be
as serious as Fanconi's syndrome with renal tubular acidosis and
glycosuria. a slow increase in serum creatinine, with a fall in eGrF and
proteinuria can all mean the patient needs to switch off this drug.
Specialist advice should be sought if this is suspected.
ureteric colic, renal and ureteric stones
atazanavir is the PI most commonly associated with these side effects,
but others are also implicated, including indinavir although this is rarely
used nowadays.
lactic acidosis and hepatic toxicity
Probably caused by all nrTIs to varying degrees but mostly drugs such
as didanosine and stavudine. These drugs are not commonly used in the
UK now, but may have been used by patients from other parts of the
world who have come to the UK. This potentially life threatening problem
may present with non-specific symptoms such as nausea, loss of
appetite or abdominal pain. In clear-cut cases patients will be obviously
unwell – acidotic, hepatomegaly, with deranged liver function and raised
serum lactate. Such patients need hospital admission and all arT
medications are usually stopped.
peripheral neuropathy
mainly caused by didanosine and stavudine, less commonly lamivudine.
management of neuropathic pain generally consists of either tricyclic
agents or anti-convulsants such as sodium valproate or gabapentin.
acupuncture can also be very helpful for some patients. anaesthetic
neuropathies are more difficult to manage and significant functional
disability sometimes results.
bone marrow suppression (anaemia, neutropenia)
Specialists will monitor this in patients on drugs that cause it; most
commonly zidovudine, stavudine and lamivudine.
pancreatitis
most commonly caused by didanosine, but also stavudine, abacavir and
lamivudine. Specialists will monitor amylase in patients on these drugs.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
case study
the dangers of being unaware of a
been correspondence from their HIV- patient's HIV treatment
specialists in the past, but no letters had The GP registrar at a large practice in inner been received in the past year. In both cases London decided to carry out, with the PCT there had been no detailed information about pharmacy advisor, a small study looking at their lipid levels although the correspondence how many patients could switch their lipid- lowering medication from more costly While the practice was some way from preparations to simvastatin. A search was automatical y switching these last two patients carried out in late 2010 and a plan devised from their present statin to simvastatin it is not involving the patients.
difficult to see how this might have happened if Although most patients were happy to staff had not been aware of the patient's HIV change, some were not and the change was status. The study was therefore discussed in not made. For three patients the registrar the practice's thrice-yearly critical incident had to liaise with the hospital specialists seminar since it provided important information about the best course of action (a and key learning. cardiologist and a lipid-specialist).
Two patients who were taking atorvastatin and rosuvastatin respectively could not be • Simvastatin is contraindicated for patients contacted. Both patients (a middle-aged on antiretroviral therapy as the risk of a male and a young female) were HIV-positive serious adverse event from drug and on antiretroviral therapy, including a interaction is extremely high.
protease inhibitor and a non-nucleoside • Any proposed change to long-term inhibitor. They were looked after by different therapy should always be discussed with HIV-specialist centres in London. There had the patient and hospital specialist.
Additional treatments for those with
Prophylaxis against opportunistic infections (OIs)
Pneumocystis pneumonia (PCP)
Patients who either have a CD4 count of less than 200 cells/μl or have
already had an episode of PCP will be offered prophylaxis. Co-trimoxazole
is the most effective agent, although drug reactions are seen commonly in
the HIV-infected patient, so some may use dapsone or nebulised
pentamidine. If the immune system recovers sufficiently following
antiretroviral medication, this prophylaxis may be discontinued once the
CD4 count is above 200 cells/μl and viral load is undetectable.
Co-trimoxazole also protects against toxoplasmosis.
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
Mycobacterium avium intracellulare
Patients with a CD4 count of less than 50 cells/μl should be offered
primary prophylaxis – usually azithromycin or rifabutin.
The patient who will not attend for specialist care
Some patients with HIV drift out of or reject specialist care. This is not as unlikely as it sounds. There are several reasons why this might happen including a bad experience at a particular specialist unit, adverse effects of arT, feeling better and believing treatment is no longer needed, overriding socio-economic or emotional problems, cultural or religious beliefs regarding disease causation and conventional medicine, or HIV-related stigma which in some communities is so pervasive that people may prefer to risk death than be seen coming out of an HIV clinic.
For more on
If the GP has managed to keep a continuing relationship with the stigma see
patient, this can be quite a stressful situation. The patient may not respond to discussion about the benefits of specialist care (with or without arT) and the need to attend. The GP should:• try to maintain their relationship and contact with the patient – this is sometimes the most they can achieve for some time • explore exactly what the patient's reasons are for not wishing to attend the HIV clinic – there may be a problem that can be addressed. In some areas there is more than one local HIV clinic to which the patient could be referred if there are concerns around confidentiality and being recognised • continue to give gentle reminders to the patient of the health benefits of specialist care – whilst trying not to jeopardise the GP-patient relationship • consider arranging (after discussion with the patient and the local lab) a CD4 count to assess how damaged their immunity is. With a high CD4 count the GP can be a bit more relaxed with the patient about the need for hospital review • discuss the possibility of prophylactic treatments (such co-trimoxazole for PCP) with those that may not accept arT • provide support to the patient's partner (if registered with you).
It is important to make sure you are fully aware of your responsibilities and what the GmC advises regarding patients who refuse specialist treatment. always discuss with your practice team and also get advice about this from your medical defence union.
HIV In PrImary Care 2nd edition Clinical care for people with HIV
Section 3
The dying patient
The advent of arT has meant that death as a result of HIV infection has become much less common. Usually it occurs in those who present with advanced disease or who are affected by other disease processes. nevertheless, deaths still occur and the primary care team is likely to be involved in decisions regarding care as death approaches. With arT it is harder to define when a patient is terminally ill, because, given time, there can be recovery of immunity following changes in choice of antiretroviral. However, the patient remains vulnerable to overwhelming infection until that happens. With this uncertainty about outcome, there is a need to integrate palliative and curative approaches to care, and the goals of HIV palliative care need to be redefined.
1. Planning care and advance decisions
Several life-threatening episodes may occur before the final terminal
event. So, if not already addressed, planning should begin early on after Advance decisions immunity has started to deteriorate.
and proxy decision- People with HIV commonly want to be in control of their care and making in medical treatment. all should be helped, if necessary, to express their treatment and requirements and preferences, which may change depending on the type research at of illness or stage of the condition. The desire for maximum patient choice in matters of care and treatment is nowhere more important than during episodes of acute, potentially life-threatening illness or when the patient is clearly approaching the terminal phase. Wherever possible, dying patients should be able to have partner, family, friends and people they trust around them, as well as appropriate medical, nursing and social care.
a well-planned death can also help those left behind to cope with their loss. In the UK, living wills or advance directives were largely developed by and for people with aIDS, though they are now used more widely. GPs may be asked to look at such documents, or contribute to their contents. In such circumstances it is always advisable to seek further advice and guidance, for example the Bma's ethical guidance.
2. Involvement of other healthcare professionals
although the course of advanced HIV disease may be more ‘up and
down' than other conditions requiring palliative care, GPs should still be
able to draw on their experience. Continuity and communication are
extremely important in palliative care, and general practice is well-suited
to providing these. The patient should be offered the support and
involvement of palliative services and community nursing if appropriate.
Some GPs can harness the support of specialist community nurses in
HIV care. Hospice care may be needed. respite care and symptom-
control are currently the most important indications for admission.
HIV In PrImary Care 2nd edition Section 3
Clinical care for people with HIV
3. Wills
People with deteriorating immunity should be advised to make a will as a
matter of priority to avoid distressing disagreements and resentment after
death. Civil partnership legislation provides full legal recognition for gay
partners. However, regardless of civil partnership legislation, the will and
testament is the document recognised by law and, if in doubt, patients
should be advised to seek legal advice.
4. Death certification
The issue of death certification for people who have died of HIV-related
illness can be complicated. It is commonly accepted that confidentiality Confidentiality at persists after death and there are ethical considerations regarding such confidentiality when a patient or their relatives do not wish HIV to be recorded as a cause of death due to the stigma surrounding it. However, there is a clear legal requirement to indicate on the death certificate any underlying condition which may have contributed to a patient's death, and while this may potentially cause conflict with a patient's or their relatives' wishes, the clinician's duty to comply with the law is clear and unambiguous.
Until recently, in cases of HIV-related deaths, doctors have stated the obvious cause of death – for example, bronchopneumonia – but ensured that the box on the back of the certificate is ticked so that further information can be given at a later date. This has been crucial for the accuracy of national and regional statistical information. Increasingly, however, and in particular as a result of the Shipman Inquiry and the rise in deaths from hospital acquired infections, it has become clear that this area is under renewed scrutiny.
HIV In PrImary Care 2nd edition In tHIS SectIon
Sexual health promotion and HIV prevention in the practice Working with those with diverse needs Practice policies and systems HIV In PrImary Care 2nd edition Section 4
HIV and the practice team
HIV and the practice There is a place for HIV prevention in the daily activities of the primary care team. Practice policies and systems, and appropriate training, can help to ensure that the patient with HIV receives high-quality care and staff are adequately prepared to provide this.
Sexual health promotion and HIV prevention in
the practice
Growing concerns about the deterioration of sexual health in the UK is leading some practices to consider how they might play a part in promoting sexual health and reducing HIV transmission. For this role, clinical workers in primary care need both factual information and skills in sexual history taking and risk assessment.
For more, see BASHH/ The British association for Sexual Health and HIV and medFaSH medFASH (2010) Standards have published Standards for the management of sexually for the management of transmitted infections (STIs) which provide clear guidance for all sexually transmitted infections services that manage STIs. Standard 3, The clinical assessment, (STIs) at www.bashh.org and covers the need for appropriate history taking and Standard 2, appropriately trained staff, covers competence and training.
Practice nurses and GPs have opportunities to:• discuss and assess risk of having or acquiring HIV with individual • promote safer sexual practices and condom use with those who are or • promote HIV testing when appropriate• promote hepatitis B testing and immunisation when appropriate• support harm minimisation with injecting drug users.
For more, see Belfield T, matthews Sexual health promotion interventions may occur during: P & moss c (eds) • travel advice consultations (2011) The • new patient checks handbook of sexual • contraceptive care health in primary • cervical screening.
care. london: FPA HIV In PrImary Care 2nd edition HIV and the practice team
Section 4
Post-exposure prophylaxis following sexual exposure (PEPSE)
PePSe is a course of arT of ered to the uninfected sexual partner of BASHH (2006) UK Guideline for the someone known to have HIV in order to prevent infection after sex without use of post- a condom (or in the event of a condom rupturing). It is also sometimes of ered to individuals who have had unprotected sex with someone from a prophylaxis for HIV high-risk group whose HIV status is unknown. Victims of sexual assault following sexual may also be of ered PePSe, depending on the risk assessment.
exposure at It is only recommended when the individual presents within 72 hours of exposure, and should be given as early as possible within this time frame.
PePSe is available from HIV and GUm clinics and from emergency Departments. anyone presenting to primary care for PePSe needs to be BASHH (2011) UK referred without delay to a specialist service where they can be assessed National Guidelines according to British association for Sexual Health and HIV guidelines.
on the Management of Adult and Adolescent Working with those with diverse needs
Complainants of Sexual Assault at www.bashh.org GPs are well placed to work with a wide range of people as they know their practice population well. It is well known that HIV can affect and infect anyone, but in the UK it is still most common in certain population groups. These are:• men who have sex with men• people from countries of high HIV prevalence especially Sub-Saharan africa, but increasingly the Caribbean • injecting drug users.
1. HIV stigma – a real issue
members of al these groups may already feel marginalised or stigmatised
in UK society and this can be exacerbated by the stigma and discrimination
associated with HIV. Practitioners in primary healthcare need to be aware of
some of the emotional and social pressures on these groups.
HIV infection is widely known to be incurable and people are afraid of contracting it. The link between sex or drug injecting and illness means that people who contract HIV are often thought to have brought it upon themselves as a result of personal irresponsibility or immorality. These factors combine to create a stigma that underpins prejudice, discrimination and even violence towards people with HIV. negative attitudes to HIV are often reinforced in media coverage of the issue.
The impact of stigma
Stigma leads to some people not seeking HIV testing or being reluctant to
agree to an HIV test, despite knowing they might be at risk. Others may not
be aware that they could be infected, do not think that they belong to a group
vulnerable to HIV, or may have little understanding about HIV transmission.
HIV In PrImary Care 2nd edition Section 4
HIV and the practice team
Few people with HIV feel able to be completely open about their status. a significant number do not tell employers or work colleagues or even close family members and friends. Some do not feel able to confide in their sexual partners or spouses for fear of rejection or abuse. The isolation and fear of being ‘found out' and of possible rejection or discrimination, can lead to stress and depression.
Sometimes these fears are unfounded and confiding in trusted family members and friends can provide great support, but not always. Pregnant women have been subjected to physical violence, evicted from shared homes and ostracised by their communities when discovered to have HIV.
Support against stigma and discrimination
People with HIV are now covered from the point of diagnosis by the
For more, see NAm provisions of the equality act 2010. This offers protection against (2006) HIV and discrimination in a variety of fields, including employment and the Stigma at provision of goods, facilities and services. Voluntary and community organisations which provide support and services for people with HIV have helped many to cope with both the medical and social consequences of a positive HIV diagnosis.
2. Men who have sex with men (MSM)
This term is used to include both men who identify as homosexual (and
may call themselves gay) and those who have sexual encounters with
other men without considering themselves to be homosexual. Gay men
may have a sense of belonging and access to gay-oriented culture.
However, other men who have sex with men often see themselves as
bisexual or even heterosexual, are sometimes married, and may not be
open about their same-sex encounters.
If a gay patient has a long-term partner, the practice can play a supporting role. Being registered with the same practice may make the partner's needs (for example, as a carer) easier to address. Civil partnerships provide same-sex couples with the same rights as married couples, including next-of-kin status.
3. Migrants from areas of high HIV prevalence
In the UK, people from Sub-Saharan africa and parts of the Caribbean are
known to be at higher risk of HIV infection. Communities from dif erent
parts of africa and the Caribbean can be quite distinct in their culture and
attitudes but HIV-related fear and prejudice are often very high, with
resultant stigma and secrecy. many people from high prevalence countries
wil know of family members or friends who have, or have died from, HIV.
However, there is often a great reluctance to acknowledge this openly due
to stigma. HIV may af ect both parents as wel as the children (infected or
not), creating major family needs. Diagnosis in an adult should prompt
HIV In PrImary Care 2nd edition HIV and the practice team
Section 4
consideration of possible infection in their children, who may have been born in a country not intervening to prevent mother-to-child transmission.
Cultural and religious beliefs may af ect how people cope with a diagnosis of HIV and their beliefs about il ness and treatment. It is important to present information in a cultural y sensitive way and check patients' understanding – it has been known for people with limited English to hear ‘the result is positive' as meaning that they are not infected with HIV. Beliefs should be explored in an open and non-judgemental manner, as they may af ect future adherence to treatment. Have patient information leaflets about HIV available and give contact details of local support groups and HIV services. The GP's knowledge of the local community helps in providing a focus of care for families af ected by HIV.
In many of the countries in these areas, attitudes to homosexuality are hostile and some have laws which criminalise sex between men. Men from these areas may therefore be less likely than those from the UK to disclose sexual activity with other men.
Some people with HIV are asylum seekers or refugees who have lost family members to violence and have fled their country. Some asylum seekers may ultimately be returned to countries where HIV treatment is unavailable to them.
Worries about employment, immigration or asylum can compound anxiety about confidentiality and disclosure of HIV status. When finding interpreters, it is important to be aware of HIV stigma and concerns about confidentiality within their community.
Global prevalence of HIV, 2009
Figure 7 Global prevalence of HIV 2009 HIV IN PRIMARY CARE 2nd edition Section 4
HIV and the practice team
4. Injecting drug users
Those who have acquired HIV through injecting drugs (even if they no
For more, see the longer use them) may be aware of a double stigma – as drug users they Substance misuse are a socially excluded group, and this may be compounded by their HIV management in general practice status. Those who have not wished, or been unable, to access support website (SmmgP), may be locked in a cycle of problems as they try to fund and feed their drug use. Dependent drug use may restrict the ability to attend appointments or take medication regularly. For some, HIV may not be a priority in the face of the daily problems associated with drug dependence. Low self-esteem, being in prison, previous abuse and other psycho-emotional problems may be underlying issues.
GPs involved in appropriate substitute prescribing in primary care will be aware of the benefits of this for the patient, in terms of harm reduction and access to healthcare. Do not assume that all injecting drug users are fully aware of the risks of sharing equipment or using non-sterile needles. It does no harm to repeat and reinforce the message.
5. Support organisations
There may be organisations offering support to mSm, africans or other
migrants with HIV infection in your area – your patient may (or may not)
wish to be put in touch. Local organisations offering support to drug
users may provide specific services for those with or at risk of HIV.
Practice policies and systems
1. Ensuring confidentiality and avoiding discrimination
Some patients with HIV perceive negative attitudes towards them from
some GPs and health centres. many have fears relating to confidentiality,
especially around sensitive information such as HIV status, sexual
orientation or lifestyle. Fear of breach of confidentiality is one of the main
reasons patients with HIV cite when deciding whether or not to allow the
hospital to communicate with their GP.
Developing a practice that is alive to patient concerns about confidentiality and fears of discrimination will support:• open discussion of, and testing for, HIV with those who may be at risk• disclosure of HIV status by those who already know they are infected• open discussion about safer sexual and injecting practices • improved quality of care for people with HIV infection.
HIV In PrImary Care 2nd edition HIV and the practice team
Section 4
Several studies have shown that the following interventions help in allaying the fears of patients:• ensuring that your practitioners and clinicians are non-judgmental and empathic to different lifestyles. Consider in-house training for the team • developing and implementing a non-discrimination policy with your practice – then displaying it to your patients • developing and implementing an appropriate confidentiality statement – then displaying it to your patients.
(There are examples of these in the Sexual Health module of the e-GP programme – see page 102 for details.) Practices which gain a reputation for being ‘HIV-friendly' may see an increase in registrations from people with HIV as they exercise their right to choose their GP and ‘shop around' to find the right practice.
2. Systems and record keeping
To support HIV testing
There are different systems to support HIV testing in the practice:
For aide-memoire
• a pro forma record sheet or computer template can be used to collect see page 90
data on individuals having an HIV test • an aide-memoire (computer or paper-based) may help ensure that all issues are covered.
The contents of a pro forma should be discussed and agreed with clinical team members – there is a potential that highly confidential information of little value to future care may be unnecessarily recorded. If items are excluded for this reason then an aide-memoire or checklist may be needed. It does not record individual patient information.
For the patient with HIV
Some patients will be anxious about how their HIV status is to be
recorded in the practice. It is best to raise the subject so this issue can be
addressed and the benefits outlined (as well as the risks if the diagnosis is
not clearly recorded).
coding HIV infection
Computer systems have different options for coding HIV infection.
Computer screens should not be visible to patients, although this may be
difficult to achieve in a small consulting room. If screens are visible, the
visibility of what is recorded should be considered, noting the fact that the
patient may be accompanied when not consulting for an HIV-related
problem. The practice will need to be able to search for patients with HIV
infection in order, for example, to invite them for flu immunisation or to
invite women for annual smears.
HIV In PrImary Care 2nd edition Section 4
HIV and the practice team
records to support clinical care
The success of practice systems depends on reliable and rapid
communication to and from the hospital each time the patient has
attended and also when significant test results become available. If the
patient is keen for you to be kept updated, ask them to emphasise this to
their consultant. you can also write to the patient's HIV specialist asking
for regular updates.
records of antiretroviral and other drugs
even if drugs are prescribed solely by the hospital, a clear record should
be kept. On some practice computer systems it is possible to keep a
record of drugs prescribed ‘outside', which is the safest option as long as
each and every hospital letter is checked for medication changes.
records of cd4 count and viral load
Computer systems enable a simple template to be set up for use with
patients with HIV. The most recent blood results can then be entered
when they are made available by the hospital.
review date
a review date system can act as a reminder to check that records are up
to date. It is better to spend time chasing an absent CD4 result before
you are faced with a patient with a bad cough.
3. Health and safety
Hepatitis B immunisation
The practice should have a system to ensure that staff who handle clinical
specimens are immune to hepatitis B.
Prevention of needlestick injuries
Universal precautions in handling sharp instruments and body fluids are
essential to reduce the risk of contracting HIV or other blood-borne viral
infections in the healthcare setting. approved sterilisation procedures and
adequate disposal of sharp instruments are crucial components of this
process. It is easy to forget the number of undiagnosed blood- borne infections, so it is essential to assume that all patients A ‘high risk' needlestick are potentially infected.
injury requires rapid and decisive action. Ensure Management of needlestick injuries
all team members are a ‘high risk' needlestick injury requires rapid and decisive aware of the practice action if post-exposure prophylaxis (PeP) is to be given in time. policy on PEP.
This should be as soon as possible after the injury (within hours) to maximise effectiveness.
HIV In PrImary Care 2nd edition HIV and the practice team
Section 4
Post-exposure prophylaxis for occupational exposure
Discuss, develop and implement a practice policy on PeP with guidance
from local occupational health and/or virology and ensure all team
members are aware of its existence.
PeP policies in primary care should:• advise how to manage the wound• make clear the urgency and limited window of opportunity• clarify who should be contacted for advice in your locality and how, including out of hours • refer to locally agreed protocols for provision of PeP• take into account other blood-borne viruses such as hepatitis B and C• be adopted only in association with discussion and training.
PeP starter packs are usually held in the local hospital and, given the urgency, it is customary for PeP to be started and a thorough risk assessment to be made later. This allows for discontinuation where appropriate. It is not good practice for the affected healthcare worker to organise their own care in this situation.
The HIV-infected healthcare worker
The majority of procedures carried out in the primary care setting
(assuming appropriate infection control procedures) pose no risk of
transmission of HIV from healthcare worker to patient. employing people
infected with HIV is generally not a risk except in certain very specific
situations where patients' tissues might be exposed to a carer's blood
following injury (‘exposure prone procedures').
However, the Department of Health requires all healthcare workers See Department of who are infected with HIV to seek appropriate expert medical and Health (2005) HIV-Infected Health occupational health advice, and this should include how to modify or limit Care Workers their work practices to avoid exposure prone procedures. HIV-infected Guidance on healthcare workers must not rely on their own assessment of the risk they Management and pose to patients.
Patient Notification Department of Health guidance for england and Wales on health clearance for TB, hepatitis B, hepatitis C and HIV requires all new healthcare workers who will perform exposure prone procedures to have health checks to establish that they are free from HIV infection before See Department of appointment. Parallel guidance applies in Scotland and northern Ireland. responsibility for ensuring this in general practice is assigned to GP Health clearance for tuberculosis, While protecting the health and safety of patients, the right to hepatitis B, hepatitis confidentiality of staff and colleagues must be respected. employers C and HIV: New should assure infected healthcare workers that their status and rights as healthcare workers at www.dh.gov.uk employees will be safeguarded so far as is practicable.
HIV In PrImary Care 2nd edition Section 4
HIV and the practice team
HIV In PrImary Care 2nd edition In tHIS Sec 5
HIV testing aide-memoire Antiretrovirals by group Drug interactions – further information Drug side effects A guide to managing HIV-related problems Information to support implementation of UK HIV testing guidelines 97 Useful sources for clinicians Professional development for clinicians on HIV and sexual health 102 Useful sources for patients HIV In PrImary Care 2nd edition Section 5
HIV testing aide-memoire
Essentials
Make sure you explain:
• the benefits of testing and medical advantages of knowing one's HIV
• how the patient will get the result.
Check their contact details
• Have you arranged an appointment for the result to be given to the
Has the patient given clear consent to an HIV (or other) test?
Other areas to consider if needed
Does the patient understand:
• how HIV is transmitted?
• the difference between HIV and aIDS?
• the significance of the window period and the possible need for a
Discussion of risk
• risk to date
• Future risk/risk reduction
Discussion of implications of positive result
Discussion of implications of negative result
(ie as a wake-up call to change any risky behaviour)

Coping with the wait
• Who knows they are having the test?
• Who is it safe to tell?
Ask the patient not to drink alcohol or take recreational
drugs on day of result

HIV In PrImary Care 2nd edition Quick reference
Section 5
Other useful points to consider
• Is there any written information that should be given to the patient?
• Is the test best done in primary care?
• Should there be any associated tests (eg hepatitis B and C, syphilis)?
• Is a repeat test required to cover the window period?
• Does the patient have a supply of appropriate condoms/lubricant?
Antiretrovirals by group
This list was correct at the time of writing. Up-to-date lists of agents are available on the following websites: www.bhiva.org, www.bnf.org, and www.hiv-druginteractions.org Current antiretroviral drugs Entry inhibitors Integrase reverse transcriptase reverse transcriptase inhibitors (PIs) (EIs) inhibitors (NRTIs) inhibitors (NNRTIs) enfuvirtide (T-20) didanosine (ddI)* emtricitabine (FTC) *Rarely used in the UK.
Tablets containing more than one drugTrade name efavirenz, tenofovir, emtricitabine lamivudine, zidovudine lopinavir, ritonavir abacavir, lamivudine abacavir, lamivudine, zidovudine tenofovir, emtricitabine Trade names are not often used in the UK for single drug tablets. They are used more commonly for combination tablets which are listed above. Trade names are al given in the BNF. HIV In PrImary Care 2nd edition Section 5
Drug interactions – further information
either
Check which arT class or group the antiretrovirals in question belong to
(see table above).
Then check www.hiv-druginteractions.org
or
Use the most recent BnF – section 5.3 – www.bnf.org
Drug side effects
Psychiatric problems Diabetes (Type II) Ureteric colic, renal and uteric Lactic acidosis and hepatic toxicity probably all especially Peripheral neuropathy lamivudine (rare) Bone marrow suppression lamivudine (rare) NB: there is limited knowledge of the side effects of entry and integrase inhibitors at the time of writing as these are the newest classes of antiretrovirals. However, they appear to have a lower side effect profile than the other drugs.
HIV In PrImary Care 2nd edition Quick reference
Section 5
A guide to managing HIV-related problems
a patient with HIV who presents with symptoms might have:• problems which relate to HIV disease (check the most recent CD4 count)• side effects of arT• an unconnected problem.
Patients who have developed symptoms which relate to HIV disease might have stopped taking their medication (ask) or might have developed resistance to their arT regimen. Current CD4 counts and viral load will clarify.
For patients who have not started arT, most of the problems mentioned below will improve, become less severe and rarely occur once they are established on arT.
It is important to be aware of possible arT interactions with oral medication, see www.hiv-druginteractions.org Constitutional symptoms exclude serious causes, eg lymphoma, TB, chronic gut infection.
exclude serious causes eg tumour or may be managed in secondary or primary care, depending on cause.
exclude common causes: • thyroid deficiency • vitamin B deficiency • testosterone deficiency.
Testosterone replacement Test for calcium, renal function.
sometimes used if deficiency TFTs, FBC in all.
confirmed, seek specialist advice.
Consider arT side effects.
exclude serious causes (tumour, chronic Dietary supplementation may have a infection, opportunistic infections).
role if all potentially serious causes have been excluded.
HIV In PrImary Care 2nd edition Section 5
Skin conditionsCondition Fungal infections Generally respond to topical antifungals (often combined with topical steroids).
Prolonged or repeated treatment may be required. Oral antifungals may be indicated for some (esp. nail infections).
Will respond to antivirals such as aciclovir but longer courses at higher doses may be needed.
Long-term use of antivirals is helpful if the problem is recurrent.
Topical imiquimod or podophyllotoxin.
Molluscum Oral antibiotics are more effective and less likely to be associated with resistance than topical Topical antifungal and hydrocortisone combinations.
antifungal shampoos often helpful.
Usual management, but may be much less Will require specialist treatment.
The mouthCondition Can cause significant Systemic anti-fungal agents are effective. If discomfort and difficulty recurrent can indicate poor immune function and in eating/drinking.
need for specialist opinion.
Long-term use of antifungals occasionally indicated if the problem is recurrent.
may need referral if severe or resistant infection.
Topical oral steroid creams.
Specialists use thalidomide if troublesome.
Generally asymptomatic and does not require maintaining good oral Chlorhexidine mouth washes.
hygiene and dental care Oral metronidazole.
is important for all immunocompromised referral to dentist.
requires specialist treatment.
may disappear with effective arT.
Oral antibiotics.
referral to dentist.
HIV In PrImary Care 2nd edition Quick reference
Section 5
The rest of the gastrointestinal tractCondition may be caused by arT.
managed with either a dopaminergic agent (metoclopramide or domperidone) or agents such as levomepromazine.
Indicates severe as for oral candida (see The mouth above) but generally managed by specialists or GPwSI as usually diagnosed at endoscopy.
Loperamide for symptomatic treatment. • side effect of arT Codeine is sometimes helpful.
• pancreatic insufficiency Salmonella and campylobacter respond to ciprofloxacin or macrolides as appropriate. • HIV in the intestinal mucosa Less common organisms such as • intestinal pathogens Cryptosporidium sp and Microsporidium sp Check if could be travel- may be responsible if patient has had low CD4 related diarrhoea.
Take stool samples.
management should be guided by microscopy more likely to have lactose and culture results and information on drug intolerance and remember interactions: seek specialist advice if necessary.
coeliac too.
exclude PCP (see pages 29-30).
Community-acquired chest infections exclude TB-like infections (see page 31).
should respond to first line antibiotics.
Neurological conditions – see also page 32 for serious conditions that require admissionCondition may be caused by HIV or antiretrovirals. Pain management similar to usual approaches to neuropathic pain. Gabapentin or other drugs used in neuralgia may help.
HIV In PrImary Care 2nd edition Section 5
Topical or systemic antifungal agents (clotrimazole, fluconazole).
Systemic antifungals are sometimes used long-term to prevent recurrence.
aciclovir – may be needed in longer courses and at a higher end of the dose range than usual.
Long-term use of aciclovir or similar may be used to suppress frequent recurrences.
Frequently recurrent and more difficult to treat.
Topical therapy (imiquimod or podophyllotoxin) or cryotherapy may help. refer to GUm unless responding well to topical therapy.
anal intraepithelial neoplasms and anal squamous cell carcinomas are much more common in the HIV- positive population so referral for anoscopy is indicated if there are atypical features.
may be multifactorial. Phosphodiesterase inhibitors can be used, but HIV-related causes include: they interact with PIs and nnrTIs and expert • effect of HIV advice should be sought.
• fear of transmitting infection Testosterone replacement is sometimes used on specialist advice.
There is increasing evidence that erectile • vascular problems.
dysfunction can predict underlying vascular In men check testosterone problems and hence increased risk for Stress is common.
Supportive counselling and/or may be exacerbated by stigma.
specialist or psychological support is may be seen more commonly in people Beware drug interactions if Some antiretrovirals may be associated with psychiatric disturbance.
HIV-related brain Can cause functional impairment and Seek specialist advice.
lead to significant care needs.
Consider needs of carer(s).
Visual problemsSee page 33 for CmV retinitis, a serious condition that requires urgent referral to ophthalmology.
HIV In PrImary Care 2nd edition Quick reference
Section 5
Information to support implementation of UK HIV
Clinical indicator diseases for HIV infection
The UK National Guidelines for HIV Testing 2008 recommend offering an HIV test to every patient presenting with a clinical indicator disease for HIV infection. (See table for adults on following page.) See www.bhiva.org Clinical indicator diseases for paediatric HIV infection AIDS-defining conditions Other conditions where HIV testing should Chronic parotitis,recurrent and/or troublesome ear infections recurrent oral candidiasisPoor dental hygiene recurrent bacterial pneumonia Lymphoid interstitial pneumonitis HIV encephalopathy Developmental delay Severe or recalcitrant dermatitismultidermatomal or recurrent herpes zosterrecurrent fungal infectionsextensive warts or molluscum contagiosum Gastroenterology Wasting syndrome Unexplained persistent hepatosplenomegaly Hepatitis B infectionHepatitis C infection LymphomaKaposi's sarcoma any unexplained blood dyscrasia including: • thrombocytopenia Testing 2008 • neutropenia• lymphopenia any unexplained retinopathy recurrent bacterial infections (eg meningitis, sepsis, UK National Guidelines for HIV osteomyelitis, pneumonia etc)Pyrexia of unknown origin HIV In PrImary Care 2nd edition Section 5
Clinical indicator diseases for adult HIV infection Other conditions where HIV testing should be Bacterial pneumonia Cerebral toxoplasmosis Primary cerebral Space occupying lesion of unknown cause Cryptococcal meningitis Guillain-Barré Syndrome Progressive multifocal Transverse myelitis Severe or recalcitrant seborrhoeic dermatitisSevere or recalcitrant psoriasismultidermatomal or recurrent herpes zoster Oral hairy leukoplakiaChronic diarrhoea of unknown causeWeight loss of unknown causeSalmonella, shigella or campylobacterHepatitis B infectionHepatitis C infection anal cancer or anal intraepithelial dysplasia Lung cancerSeminomaHead and neck cancer Hodgkin's lymphoma Castleman's disease Vaginal intraepithelial neoplasiaCervical intraepithelial neoplasia Grade 2 or above any unexplained blood dyscrasia including: • thrombocytopenia Infective retinal diseases including herpesviruses and toxoplasmaany unexplained retinopathy Testing 2008 Lymphadenopathy of unknown causeChronic parotitisLymphoepithelial parotid cysts mononucleosis-like syndrome (primary HIV infection)Pyrexia of unknown originany lymphadenopathy of unknown cause UK National Guidelines for HIV any sexually transmitted infection HIV In PrImary Care 2nd edition Quick reference
Section 5
Local diagnosed HIV prevalence
The UK National Guidelines for HIV Testing 2008 suggest an HIV test should be routinely offered as part of new patient checks in general practice, where local diagnosed HIV prevalence is over two per 1,000 population. A data table of diagnosed HIV prevalence for each PCT and local authority in England can be found on the ‘HIV & STIs/data for commissioners' page of the HPA website (www.hpa.org.uk).
Figure 8 HIV-infected individuals accessing HIV care by area of residence in 2009: Rate per 1,000 aged 15-59 years Health Protection HIV IN PRIMARY CARE 2nd edition Section 5
Useful sources for clinicians
Reference documents to bookmark or keep in the practice
association of British Insurers & British medical association (2010) Medical information and insurance. Joint guidelines from the British Medical Association and the Association of British Insurers. London: British medical association. available at www.bma.org.uk Belfield T, matthews P & moss C (eds) (2011) The handbook of sexual health in primary care. London: FPa.
British association for Sexual Health and HIV, British HIV association, British Infection Society (2008) UK National Guidelines for HIV Testing 2008. available at www.bhiva.org, www.bashh.org and www.britishinfection.org British association for Sexual Health and HIV and medical Foundation for aIDS & Sexual Health (2010) Standards for the management of sexually transmitted infections (STIs). available at www.bashh.org or www.medfash.org.uk British HIV association (2008) Guidelines for the immunization of HIV-infected adults. HIV Med 9: 795-848. available at www.bhiva.org British HIV association & Children's HIV association (2008) Guidelines for the management of HIV infection in pregnant women. available at www.bhiva.org British National Formulary section 5.3. available at www.bnf.org Department of Health Immunisation against infectious disease (‘The Green Book'). Updated regularly at www.dh.gov.uk General medical Council (2009) Confidentiality. London: General medical Council. available at www.gmc-uk.org University of Liverpool HIV Pharmacology Group. Comprehensive listings of interactions between HIV drugs and others, including herbal medicines and recreational drugs. They will answer individual queries from doctors. available at www.hiv-druginterations.org HIV In PrImary Care 2nd edition Quick reference
Section 5
Organisations and websites
aidsmap
www.aidsmap.com
extensive information on treatments, including updates on the latest
research. Database of HIV organisations worldwide (including UK).
British Association for Sexual Health and HIV (BASHH)
www.bashh.org
medical specialist society for professionals in GUm/HIV that produces
clinical effectiveness guidelines for the management of STIs.
British HIV Association (BHIVA)
www.bhiva.org
regularly updated guidelines for the treatment and care of HIV-infected
adults including HIV testing, treatment with arT, HIV in pregnancy, HIV
and hepatitis co-infection, immunisation, sexual and reproductive health,
adherence support and management of other co-morbidities.
Children's HIV Association of the UK and Ireland (CHIVA)
www.chiva.org.uk
articles and protocols on treatment and care of HIV-infected children and
information on the Children's HIV national network (CHInn).
Health Protection Agency (HPA)
www.hpa.org.uk
Up-to-date figures for HIV and other infections in the UK, including graphs
and slides that can be downloaded.
NHS Evidence
www.evidence.nhs.uk
a wealth of journal papers guidelines and other useful information
Royal College of General Practitioners' Sex, Drugs and HIV
Group
www.rcgp.org.uk/substance_misuse/sex drugs_and_hiv_group.aspx
a special interest group concerned with education and policy. Organises
national conferences.
Scottish HIV and AIDS Group (SHIVAG)
www.shivag.co.uk
Professional website with news, discussion forums and useful documents
regarding HIV in Scotland.
HIV In PrImary Care 2nd edition Section 5
Substance misuse management in general practice
(SMMGP)
www.smmgp.org.uk
Organisation providing information and support to GPs prescribing for
drug users. Produces a regular newsletter.
Professional development for clinicians on HIV and
Listed below are the most important CPD options for those interested in HIV and sexual health.
e-learning
This is a selection of e-learning specifically about HIV. HIV is also
mentioned in modules about conditions associated with HIV, such as
sexually transmitted infections, viral hepatitis and tuberculosis.
e-learning for healthcare sessions
http://e-lfh.org.uk/projects/egp
e-GP is rCGP education for GPs and practice nurses on topics within the
GP curriculum. relevant modules include:
GPS 11 001 Sexual Health – Indicators of risk
GPS 11 002a The Sexual History – Sexual History Taking in the General
Practice Context
GPS 11 002b The Sexual History – The Partner History
GPS 11 002c The Sexual History – assessing Condom Use, Pregnancy
risk and Symptoms
GPS 11 014a HIV and Why early Diagnosis matters
GPS 11 014b HIV Indicator Conditions
http://e-lfh.org.uk/projects/hiv-stieHIV-STI has been developed by BaSHH and the Federation of the royal Colleges of Physicians for healthcare professionals treating and supporting people with sexually transmitted infections, including HIV. relevant modules include:HIV-STI 01 02 Sexual HistoryHIV-STI 11 01 HIV TestingHIV-STI 11 03 HIV Disclosure and Partner notificationHIV-STI 12 01 natural History of HIV InfectionHIV-STI 12 07 antiretroviral Side effects and Toxicities HIV In PrImary Care 2nd edition Quick reference
Section 5
Royal College of General Practitioners Online Learning
Environment
www.elearning.rcgp.org.uk
Sexual health in general practice
This e-module forms part of the Introductory Certificate in Sexual Health
but can also be completed as a stand-alone. It covers HIV testing and
diagnosis.
BMJ Learning
www.group.bmj.com/products/learning
relevant modules are:
Testing for HIV in general practice in the UK
HIV infection: diagnostic picture tests
Introductory Certificate in Sexual Health (ICSH)
royal College of General Practitioners
www.rcgp.org.uk/substance_misuse/sex drugs_and_hiv_group/intro_
cert_in_sexual_health.aspx
One-day educational event for GPs and practice nurses with no previous
training in sexual health. a useful first step. Participants should complete
the e-module ‘Sexual health in general practice' before attending.
Sexually Transmitted Infections Foundation (STIF) course
British association for Sexual Health and HIV
www.bashh.org/stif
multidisciplinary training in the attitudes, skills and knowledge required for
the prevention and management of STIs, including sexual history taking
and HIV testing in non-GUm settings using a variety of educational
techniques. The course comprises five to six hours of e-learning and one
or two days of face-to-face training.
STIF competency
British association for Sexual Health and HIV
www.bashh.org/stif_ic
a modular competency-based training and assessment package for
non-specialist healthcare professionals requiring more specialist skills in
STI management.
HIV In PrImary Care 2nd edition Section 5
Useful sources for patients
Leaflets to have in the practice
HIV FPa
www.fpa.org.uk/professionals/publicationsandresources
an information leaflet about HIV and HIV testing for the general public.
available free to general practices in england in multiples of 50 copies. In
the rest of the UK £7.50 per 50 copies.
To order, email allocations@fpa.org.uk
Downloadable pdf on the website.
Your Next Steps Terrence Higgins Trustwww.tht.org.uk/informationresources/publicationsThis booklet is for people who have just found out they have HIV.
Up to three copies free of charge, 35p per copy in bulk.
To order, call 0845 12 21 200 or online at the website.
Downloadable pdf on the website.
Other printed resources for people with HIV
NAM patient information booklets
www.aidsmap.com/resources/booklets
Plain english information on testing, treatment and living with HIV
(14 booklets).
available free to people living with HIV. For organisations, £1 each.
To order, call 020 7840 0050, email info@nam.org.uk or online at the
website.
Downloadable pdfs on the website.
Terrence Higgins Trust Living with HIV booklet series
www.tht.org.uk/howwecanhelpyou/livingwithhiv
Information to enable people living with HIV to remain well informed and
positive about life.
Up to three copies free of charge, 35p per copy in bulk.
To order, call 0845 12 21 200 or online at the website.
Downloadable pdfs on the website.
Websites for HIV information
aidsmap
www.aidsmap.com
a wealth of easy-to-read information on HIV and arT. Some online
information resources available in French, Portuguese, Spanish,
romanian and russian.
HIV In PrImary Care 2nd edition Quick reference
Section 5
AVERT (AIDS education and research)
www.avert.org
abundant information on HIV-related education, prevention and care,
including information for young people, statistics and information about
transmission, treatment and testing.
HIV i-base
www.i-base.info
HIV information for healthcare professionals and HIV-positive people
including information on HIV treatment guidelines, answers to HIV
treatment questions and materials for advocacy.
National AIDS Trust
www.nat.org.uk
a national policy organisation. Useful information on legal and policy
issues for people with HIV and professionals.
Terrence Higgins Trust
www.tht.org.uk
Sections of website for people with HIV and for others requiring sexual
health information.
Organisations for support and information
you may well have local organisations working with people with HIV.
Here we list just a few national organisations which may help you or your patient to identify local ones.
African AIDS Helpline
http://africaninengland.org.uk
0800 0967 500
mon – Fri (except bank holidays), 10am – 6pm.
(answerphone service available outside these hours.)
Languages available: english, French, Portuguese, Luganda, Shona and
Swahili.
HIV Support Centre
www.thehivsupportcentre.org.uk
Provides support services and information in northern Ireland.
Helpline: 0800 137 437
HIV In PrImary Care 2nd edition Section 5
Positively UK (formerly Positively Women)
www.positivelyuk.org
a national charity championing the rights of people living with HIV.
People living with HIV answer the helpline and wil ring back free of charge.
Helpline: 020 7713 0222
mon – Fri, 10am – 5pm (Thurs until 8pm).
Sexual health information line
0800 567 123 (calls may be charged from mobile phones).
24-hour, free, confidential helpline for anyone concerned about HIV or
sexual health. Translation services available and can provide details of
local HIV organisations.
Terrence Higgins Trust
www.tht.org.uk
a large charitable organisation with services in many British towns and
cities. Produces a wide range of written resources on HIV prevention and
living with HIV.
THT Direct helpline: 0845 1221 200
mon – Fri 10am – 10pm, Sat/Sun 12pm – 6pm.
Waverley Care
www.waverleycare.org
Charity providing support services and information in Scotland.
Information centre: 0131 661 0982
HIV In PrImary Care 2nd edition Quick reference
Section 5
association of British Insurers & British medical association (2010) Medical information and insurance: joint guidelines from the British Medical Association and the Association of British Insurers. available at www.bma.org.uk (accessed 18 march 2011) Belfield T, matthews P & moss C (eds) (2011) The handbook of sexual health in primary care. London: FPa.
British association for Sexual Health and HIV (2010) BASHH Statement on HIV window period 15 march 2010. available at www.bashh.org (accessed 14 January 2011) British association for Sexual Health and HIV (2010) UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault. available at www.bashh.org (accessed 14 January 2011) British association for Sexual Health and HIV (2006) UK Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. available at www.bashh.org (accessed 14 January 2011) British association for Sexual Health and HIV, British HIV association, British Infection Society (2008) UK National Guidelines for HIV Testing 2008. available at www.bhiva.org, www.bashh.org and www.britishinfection.org (accessed 14 January 2011) British association for Sexual Health and HIV and medical Foundation for aIDS & Sexual Health (2010) Standards for the management of sexually transmitted infections (STIs). available at www.bashh.org and www.medfash.org.uk (accessed 14 January 2011) British association for Sexual Health and HIV, British HIV association, Faculty of Sexual and reproductive Healthcare (2008) UK guidelines for the management of sexual and reproductive health of people living with HIV infection. available at www.bhiva.org (accessed 14 January 2011) British HIV association (2008) Guidelines for the immunization of HIV-infected adults. available at www.bhiva.org (accessed 14 January 2011) HIV In PrImary Care 2nd edition Section 5
British HIV association (2008) Guidelines for the management of coinfection with HIV-1 and hepatitis B or C virus. available at www.bhiva.org (accessed 14 January 2011) British HIV association (2008) Guidelines for the treatment of HIV-1 infected adults with antiretroviral therapy. available at www.bhiva.org (accessed 14 January 2011) British HIV association, British association for Sexual Health and HIV, British Infection Society, royal Col ege of Physicians (2007) Standards for HIV Clinical Care. available at www.bhiva.org (accessed 14 January 2011) British HIV association and Children's HIV association (2008) Guidelines for the management of HIV infection in pregnant women. HIV Med 9: 452-502. available at www.bhiva.org (accessed 14 January 2011) British medical association (2007) Advance decisions and proxy decision-making in medical treatment and research – guidance from the BMA's Medical Ethics Department. available at www.bma.org.uk (accessed 14 January 2011) Department of Health (2005) HIV-infected health care workers: Guidance on management and patient notification. available at www.dh.gov.uk (accessed 14 January 2011) Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. available at www.dh.gov.uk (accessed 14 January 2011) Department of Health, Social Services and Public Safety of northern Ireland (2009) HIV-infected health care workers: Guidance on management and patient notification. available at www.dhssps.gov.uk (accessed 27 February 2011) Department of Health, Social Services and Public Safety of northern Ireland (2009) Health Clearance for Tuberculosis (TB), Hepatitis B, Hepatitis C and HIV: New Healthcare Workers with Direct Clinical Contact with Patients. available at www.dhsspsni.gov.uk (accessed 18 march 2011) expert advisory Group on aIDS (2006) Oral sex and transmission of HIV – statement of risk. available at www.dh.gov.uk (accessed 14 January 2011) HIV In PrImary Care 2nd edition Quick reference
Section 5
Faculty of Sexual and reproductive Healthcare (2009) UK Medical Eligibility Criteria for Contraceptive Use. available at www.fsrh.org (accessed 27 January 2011) Faculty of Sexual and reproductive Healthcare (2011) Clinical Guidance: Drug Interactions with Hormonal Contraception. available at www.fsrh.org (accessed 14 January 2011) General medical Council (2009) Confidentiality. available at www.gmc-uk.org (accessed 14 January 2011) Health Protection agency (2010) HIV in the United Kingdom: 2010 Report. available at www.hpa.org.uk (accessed 14 January 2011) Health Protection agency (2010) Time to test for HIV: expanded healthcare and community HIV testing in England. available at www.hpa.org.uk (accessed 14 January 2011) Leake-Date H & Fisher m (2007) HIV Infection. In: Whittlesea C & Walker r (eds) Clinical Pharmacy and Therapeutics 4th edition. Oxford: Churchill Livingstone.
nam (2006) HIV and stigma. available at www.aidsmap.com (accessed 14 January 2011) Department of Health (2003) Screening for infectious diseases in pregnancy: Standards to support the UK antenatal screening programmeavailable at www.dh.gov.uk (accessed 18 march 2011) Scottish Government (2005) HIV-Infected Health Care Workers: Guidance on Management and Patient Notification. available at www.scotland.gov.uk (accessed 27 February 2011) Scottish Government (2008) Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV for new Healthcare Workers with direct clinical contact with patients. available at www.scotland.gov.uk (accessed 18 march 2011) Welsh assembly Government (2005) HIV-Infected Health Care Workers: guidance on management and patient notification. available www.wales.nhs.uk/documents (accessed 18 march 2011) HIV In PrImary Care 2nd edition Section 5
HIV In PrImary Care 2nd edition HIV In PrImary Care 2nd edition Section 6
Notes: page numbers suffixed by ‘f' indicate figures, by ‘i' indicate images and by ‘t' indicate tables.
interactions 60, 70-71, 92t abacavir 71, 74, 91t, 92t abdominal pain 74 mortality, impact on 12 acquired Immune Deficiency Syndrome (aIDS) side effects 65, 69, 71-75, 92t, 95t, 96t viral load 18, 20, 61, 63, 64, 69, 70 adherence 70, 73, 93t advance directives 77 aphthous ulceration 36, 94t african communities 19, 82-83 areas of high prevalence in UK 46, 55, 99f aide-memoire 50, 51, 85 aidsmap website 60, 61, 82, 101 aspergillosis 98t alcohol 51, 59, 90 assisted conception 62 anaemia 38, 39, 74, 93t association of British Insurers (aBI) 43 asylum seekers 64, 83 asymptomatic HIV infection 14, 18, 24, 45 anal squamous cell carcinomas 96t, 98t atazanavir 74, 91t, 92t Atripla 91t antenatal care 20, 44, 46 in patients with HIV 60, 63 support after positive result 58 aZT see zidovudine antibiotics 31, 39, 40, 41, 94t, 95tantibody test see testing (HIV antibody/antigen antiretroviral therapy (arT) 19 bacterial infections 14, 30, 31, 35, 98t adherence 70, 73, 93t breastfeeding and 64 BCG vaccination 59 cardiovascular risks 59, 67 benefits of testing 49 caring for people on 67-75 bipolar disorder 96t CD4 cell counts 17t, 69 blood donation 21 combinations of drugs used 69 blood pressure 59 contraceptives and 62 BnF 66, 71, 91t, 92t, 100 current drugs 19, 91t dying patients 77 bone marrow suppression 74, 92t HIV In PrImary Care 2nd edition Subject index
Section 6
bottle feeding 63-64 cervical screening 46, 59, 60, 80 breastfeeding 20, 63-64 chest infections 30 British association for Sexual Health and HIV (BaSHH) 15, 16, 24, 43, 50, 61, 80, 81, 100, management 31, 95t 101, 102, 103, 107 children with HIV 59, 82, 97t British HIV association (BHIVa) 16, 20, 24, 43, Children's HIV association of the UK and Ireland 59, 61, 64, 66, 67, 91, 97, 100, 101, 107, 108 British Infection Society (BIS) 16, 100, 107 chlorhexidine mouth washes 94 British medical association (Bma) 43, 77 bronchiectasis 97t ciprofloxacin 95t clinical care for people with HIV 58-78clinical diagnosis of HIV see clinical indicator clinical indicator conditions 25-43, 97t, 98t Caesarian section 20 CmV see cytomegalovirus calcium tests 93t co-morbidities 67 Campylobacter species 98t co-trimoxazole 75, 76 see also oesophageal candidiasis; oral combination therapy 19, 21, 40, 62, 69-70, 91t candidiasis; oropharyngeal candida combined HIV antibody and p24 antigen tests 15 cardiovascular diseases 59, 67 Combivir 91t Caribbean communities 19, 82-83 Castleman's disease 98t cultural sensitivity 83 how to offer an HIV test 25, 38 and arT 17t, 25, 69, 72 useful phrases to offer an HIV test 47-49 asymptomatic HIV infection 14, 18 community-acquired bacterial pneumonia 30, computer templates 85 HIV problems and 17t, 29, 40, 41, 65, 93t condoms 20, 52, 56, 61, 62, 80, 81, 91 Mycobacterium avium intracellulare 31, 76 PCP 29, 30, 31, 75 barriers to HIV testing 25 primary HIV infection 27 death certificates 78 GmC guidance 43, 78, 100 sites of drug action 68 HIV-infected healthcare workers 87 patients with HIV 25, 58, 76, 83, 84 and viral load 18, 18f, 86, 93 practice policies 25, 84-85 cerebral abscess 98t pre-test discussion 51, 90 cerebral lymphomas 30, 32 cerebral toxoplasmosis 17, 32, 98t constitutional symptoms 35 cervical cancers 14, 34, 98t contact details 50, 90 continuing professional development (CPD) 102 in patients with HIV 59, 60 cervical lymphadenopathy see lymphadenopathy in patients with HIV 62 HIV In PrImary Care 2nd edition Section 6
diphtheria vaccination 59 cost-effectiveness 69 Disability Discrimination act 82 discrimination 85 counselling see pre-test discussion criminal prosecution of HIV transmission 61 dopaminergic agents 95t cryotherapy 94t, 96t drug interactions 60, 70-71, 92 cryptococcal meningitis 17, 32, 98t drug resistance 69-70 cryptococcosis 15 cryptosporidiosis 15, 95t, 97t, 98t culture 76, 82, 83cytomegalovirus (CmV) 15, 33, 65, 98t e-learning resources 102-103efavirenz 62, 72, 91t, 92t ellaOne see ulipristal acetate d4T see stavudine emtricitabine 91t enT conditions 97t, 98t ddI see didanosine entry inhibitors (eIs) 19, 68f, 91t death certificates 78 death of patients 77-78 erectile dysfunction 96t deaths from HIV see mortality erythrocyte sedimentation rate (eSr) 41 etravirine 62, 91t dental abscesses 36, 94t dental hygiene 97t expert patients 58 eye conditions 97t, 98t Department of Health 20, 59, 87depression 62, 64, 65, 73, 82, 96t see also mental health Faculty of Sexual and reproductive Healthcare developmental delay 97t (FSrH) 61, 62, 107, 109 diabetes 19, 59, 72, 73-74, 92t false positivity rates of HIV tests 16 family members 58, 65, 77, 82, 83 fatigue 26, 39, 41 in primary care 24-55 diarrhoea 15, 29, 36, 40, 98t fever 26, 30, 31, 32, 34, 35, 39, 41 and international travel 60 see also pyrexia of unknown origin primary HIV infection 27 didanosine (ddI) 74, 91t folliculitis 25, 35 diet 59, 64, 70, 93t diffuse hypergammaglobulinaemia 38 fosamprenavir 91t HIV In PrImary Care 2nd edition Subject index
Section 6
FTC see emtricitabine fungal infections 14, 35, 97t hepatitis C 59, 61, 67 hepatosplenomegaly 97t herbal remedies 70herpes simplex 35, 37, 42 management 94t, 96t herpes zoster 14i, 25, 27, 35, 38, 67, 97t, 98t gastrointestinal conditions 95t, 97t, 98t gay men see men who have sex with men General medical Council (GmC) 43, 76, 78 heterosexually acquired infection 10-12, 11f, 41 high prevalence areas in UK 46, 55, 99f how to diagnose HIV 24-55 high prevalence countries 20, 42, 45, 81, 82 policies and systems 84-87 HIV antibody test see testing (HIV antibody/ sexual health promotion 80-84 genital herpes see herpes simplex HIV seroconversion see primary HIV infection HIV-associated infections see opportunistic management 94t, 96t gingivitis 36, 94t HIV-infected healthcare workers 87 glandular fever 15, 25, 26, 35, 55 HIV-related dementia see dementia Guillain-Barré syndrome 98t Hodgkin's lymphoma 14, 98t GUm clinics 52, 55, 81, 96t gynaecologic conditions 98t homosexuals see men who have sex with menhow to give a test result 52-53hyperlipidaemia 75 hypersensitivity 71-72, 92t haematological conditions 38, 97t, 98thead and neck cancers 98theadache 27, 32 health promotion 19-21 imiquimod 94t, 96t HIV and practice team 80-81 immunisation 17, 21, 52, 59 patients with HIV 59 see also travel advice Health Protection agency (HPa) 10f, 11f, 12, immunosuppression 29 12f, 13, 46, 99, 101, 109 health and safety 86-87 hepatic metabolism 72 hepatic toxicity 74, 92t incidence of HIV 10-12, 10f, 11f hepatitis a vaccination 59, 60 incidence tests 13 hepatitis B vaccination 59, 60, 80 indinavir 65, 74, 91t, 92t health workers 86 infection control 20, 87 hepatitis B/C 41, 67, 80, 97t, 98t influenza vaccination 59, 85 healthcare workers 87 influenza-like illness see glandular fever occupational exposure 87 informed consent 49, 50 pre-test discussion 52, 91 injecting drug users HIV In PrImary Care 2nd edition Section 6
HIV testing 45, 46 new HIV diagnoses 11f lymphoepithelial parotid cysts 98t preventing transmission 21, 80 lymphoid interstitial pneumonitis 97t undiagnosed HIV infection among 12f lymphomas 30, 32, 34, 93t insurance 43-44, 51 integrase inhibitors (IIs) 19, 68f, 91t lymphopenia 38, 97t, 98t side effects 71, 92t judgmental attitudes 25, 85 maI see Mycobacterium avium intracellularemalaise see fatiguemalaria 39, 60 malignancies 14, 15, 34 Kaletra 91t maraviroc 62, 91t Kaposi's sarcoma (KS) 14, 30, 33i, 34, 34i, 36, medical Foundation for aIDS & Sexual Health (medFaSH) 50, 80, 100, 107 men who have sex with men health promotion 19, 54 Kivexa 91t hepatitis 59, 61, 67HIV diagnosis 11, 12, 28, 40, 54HIV testing 45 laboratory support 44 new diagnoses 11f labour 16, 20, 45, 60, 63 see also pregnancy undiagnosed HIV infection 12f lactic acidosis 74, 92t meningism 27, 97t, 98t lamivudine (3TC) 74, 91t, 92t meningitis vaccination 59 late diagnosis of HIV 13, 25, 39 lethargy see fatigue effect of arT on 72, 92t leucoencephalopathy 98t levomepromazine 95t in patients with HIV 64-65 Levonelle see levonorgestrel see also depression levonorgestrel 62 lipoatrophy 65, 72-73, 73i, 92t metoclopramide 95t lipodystrophy 19, 65, 72-73, 73i, 74, 92t Molluscum contagiosum 35, 42, 97t long acting reversible contraceptives 62 monitoring HIV infections 13 longstanding HIV infections 13, 26, 29-41 impact of arT on 12 lung cancers 14, 98t mother-to-child transmission 20, 45, 46, 63 lymphadenopathy 26, 34, 35, 39, 42, 98t mouth conditions 36 HIV In PrImary Care 2nd edition Subject index
Section 6
multiple sex partners 45 occupational HIV exposure 86, 87 Mycobacterium avium intracellulare (maI) 15, 31 oesophageal candidiasis 36 management 95tsee also candidiasis opportunistic infections (OIs) 14, 93t CD cell counts 17t nail infections 94t prophylaxis 75-76 natural history of HIV infection 14-15, 18f oral candidiasis 36, 37i, 97t, 98t neck stiffness 32 in primary HIV infection 27 needle exchange 21 see also candidiasis needlestick injuries 6, 21, 86 oral contraceptives 62 negative HIV test results how to give 49, 50, 51, 52 oral hairy leukoplakia 36, 37i, 98t neurological conditions 32, 66, 95t, 97t, 98t neuropathic pain 95t oral metronidazole 94t neutropenia 38, 74, 97t, 98t nevirapine 62, 71-72, 91t, 92t oral steroids 94t new HIV diagnoses 10-12 by prevention group 11f oropharyngeal candida 17t new patient registrations 55, 80 see also candidiasis night sweats 29, 30, 34, 35, 39 osteomyelitis 97t overseas travel see travel management 93tsee also fever non-Hodgkin's lymphoma 14, 98t non-nucleoside reverse transcriptase inhibitors palliative care 77 (nnrTIs) 19, 68, 69, 91t pancreatic insufficiency 95t contraceptives and 62 pancreatitis 74, 92t drug interactions 70-71, 92, 96t parents of children with HIV 59 side effects 71, 92t parotitis 97t, 98t nucleic acid amplification Tests (naaT) 16 partners of people with HIV 45, 82 nucleoside/tide reverse transcriptase inhibitors patient leaflets 104 (nrTIs) 19, 68, 69, 91t PCP see Pneumocystis pneumonia contraceptives and 62 penetrative sex 20 drug interactions 70, 96t side effects 71, 72, 74, 92t PeP see post-exposure prophylaxis nurses 50, 54, 55, 70, 80 PePSe see post-exposure prophylaxis following perianal ulcers 27 HIV In PrImary Care 2nd edition Section 6
perianal warts 96t pro forma record sheets 85 peripheral neuropathy 74, 92t, 95t, 98t progressive multifocal leucoencephalopathy pertussis vaccination 59 phosphodiesterase inhibitors 96t protease inhibitors (PIs) 19, 68-69, 91t contraceptives and 62 pinprick blood samples 16 drug interactions 70-71, 96t pityriasis versicolor 35 side effects 72, 74, 92t PmL see progressive multifocal psoriasis 35, 98t pneumococcal vaccination 59 psychiatric problems 72 Pneumocystis pneumonia (PCP) 14, 29, 30-31, see also mental health pyrexia of unknown origin 35, 39, 97t, 98t as aIDS-defining infection 15 see also fever CD4 counts 17tprophylaxis 75, 76 podophyllotoxin 94t, 96t point-of-care tests (POCTs) 16 pros and cons of use in general practice 43 polio vaccination 59 rapid testing see point-of-care tests (POCTs) polymerase chain reaction tests (PCr) 16, 18 positive HIV test results in primary HIV infection 26i, 27 how to give 49, 51, 52-53 recent Infection Testing algorithm (rITa) 13 post-exposure prophylaxis 21 record keeping 85-86 following occupational exposure 86, 87 recreational drugs 51, 90 following sexual exposure 61, 81 interactions with arT 70-71, 100 postnatal care 63 referral to specialist clinics 27, 30-38, 52, 53, practice nurses 50, 54, 55, 70, 80 pre-exposure prophylaxis (PreP) 63 refusal to attend specialist care 76 pre-test discussion 49-53 refusal to test 81 confidentiality 51, 90 hepatitis B/C 52, 91 renal problems 67, 74, 92t, 93t negative HIV test results 52, 90 renal stones 74, 92t positive HIV test results 52-53, 90 repeat testing 43, 50, 51, 52 repeat testing 90, 91 pre-test discussion 90, 91 window period 50, 90 respiratory conditions 30-31, 66, 97t, 98t pregnancy 20, 45, 60, 63 use of POCTs in 16 retinopathies 97t, 98t see also labour prevalence of HIV 10,12f prevention of HIV 19-21 risk assessment 38, 45, 50-51, 80 primary cerebral lymphoma 32, 98t ritonavir 60, 69, 72, 91t, 92t primary HIV infection 14, 26-28, 26i, 98t royal College of General Practitioners (rCGP) use of naaT to diagnose 16 Sex, Drugs and HIV Group 101 HIV In PrImary Care 2nd edition Subject index
Section 6
training in sexual health102-103 injecting drug users 84 men who have sex with men 65, 82migrants from areas of high HIV prevalence 82-83 refusal to attend specialist care 76 safer sex 20, 21, 28, 53, 60, 61, 80 HIV test discussion 27, 51 Salmonella species 98t support groups 53, 82 seborrhoeic dermatitis 25, 35i, 67, 38, 98t swine flu vaccination 59 systems and record keeping 85-86 seminoma 98tsepsis 97tseroconversion see primary HIV infection T20 see enfuvirtide tenofovir 74, 91t, 92t post-exposure prophylaxis 81 testing (HIV antibody/antigen test) 15-18 aide-memoire 90-91 benefits of 49, 90 genital conditions 96t clinical indicator diseases for adult infection 98t in patients with HIV 61 clinical indicator diseases for paediatric promotion in the practice 80-81 sexual history 45, 46, 80 how to give results 52-53, 90 training in taking 102, 103 how to offer 25, 90 sexual partners of people at high risk of HIV 28, with identifiable risk 45 opportunities in primary care 24, 44, 46 sexual y transmitted infections 20, 37, 45-46, 98t pre-test discussion 49-53, 90-91 HIV transmission risk 61 request by patient 45-46 systems and record keeping 85-86 shingles see herpes zoster testosterone deficiency 93t, 96t simvastatin 72, 75 tetanus vaccination 59 skin conditions 35, 41, 97t, 98t 3TC see lamivudine thrombocytopenia 38, 41, 97t, 98t smoking cessation 28, 59, 72 thrush see oral candidiasis thyroid deficiency 93t space occupying lesion of unknown cause 98t specialist HIV centres 44, 53 GP's communication with 66 toxoplasmosis 15, 32, 75, 98t refusal to attend 76 training 25, 80, 85, 103 transverse myelitis 98t stavudine (d4T) 74, 91t, 92t travel advice and immunisation 60, 80 stigma 58, 64, 73, 78, 81-82 HIV In PrImary Care 2nd edition Section 6
heterosexually acquired infection 41 Trizivir 91tTruvada 91ttuberculosis 30, 31, 39, 93t, 95t, 98t BCG vaccination 59 zidovudine (aZT) 74, 91t, 92t tumours see malignancies typhoid vaccination 59 UK National Guidelines for HIV Testing 2008 24, 30, 39, 43, 46clinical indicator conditions 97t, 98tpre-test discussion requirements 49-50 ulipristal acetate 62undiagnosed HIV infection 12f, 13, 43, 48Unlinked anonymous Seroprevalence Surveys 13ureteric stones 74, 92t vaccine for HIV 21vaginal intraepithelial neoplasia 98tvaginal sex 20, 61varenicline 59viral load 61, 63, 64, 69, 70 and CD4 count 18, 18f visual conditions 32, 66vitamin B deficiency 93tvoluntary organisations 82 genital 37, 96tmanagement 94t wasting 15, 17, 72-73, 97t, 98tweight loss 29, 30, 35, 39, 40, 93t wills 78window period 15-16 pre-test discussion 50, 90 HIV In PrImary Care 2nd edition Disclaimer
This content is intended for primary healthcare medical professionals situated in
the UK. The Medical Foundation for AIDS & Sexual Health ("MedFASH") tries to
ensure that the information provided is accurate and up-to-date, but we do not
warrant that it is, nor do our licensors who supply certain content referred to or
contained within our content. MedFASH does not advocate or endorse the use
of any drug or therapy contained within nor does it diagnose patients. Medical
professionals should use their own professional judgement in using this
information and caring for their patients and the information herein should not
be considered a substitute for that.
This information is not intended to cover all possible methods, standards, treatments, follow up, drugs and any contraindications or side effects. In addition this publication is designed to be general guidance and does not refer to all accepted practices. Also such standards and practices in medicine change as new data become available, and you should consult a variety of sources and check the date of publication of this document. We strongly recommend that users independently verify any practices or standards, specified diagnosis, treatments and follow up and ensure it is appropriate for your patient within your region. In addition, with respect to any prescription medication, you are advised to check the product information sheet accompanying each drug to verify conditions of use and identify any changes in dosage schedule or contraindications, particularly if the agent to be administered is new, infrequently used, or has a narrow therapeutic range. You must always check that should any drugs be referenced they are licensed for the specified use and at the specified doses in your region.
This information is provided on an "as is" basis and to the fullest extent permitted by law. MedFASH and its licensors assume no responsibility for any aspect of healthcare decided on and/or administered with the aid of this information or any other use of this information howsoever.
HIV in Primary Care HIV in Primary Care An essential guide for GPs, practice nurses and other HiV prevalence continues to rise. A quarter of the members of the primary healthcare team 86,500 people infected are still undiagnosed. Many will be using primary care. thanks to effective by Dr Sara Madge, Dr Philippa Matthews, Dr Surinder Singh and Dr Nick Theobald treatments, early diagnosis saves lives and helps a charity supported by the British Medical Association prevent new infections. About this booklet
This booklet provides essential information for GPs and the primary healthcare team on:
• the clinical diagnosis of HIV in primary care, with photographs
• how to offer an HIV test and give results
• primary healthcare for people with HIV, including reproductive health and immunisation
• how to complement specialist care
• practice policies and systems for optimal patient care and protection of staff.
HIV in Primary Care is instructive, practical and easy to use with a comprehensive indexand full colour illustrations.
‘The BMA welcomes this guidance as an important tool in helping to raise awareness and equip primary care professionals to deal with the diagnosis and treatment of HIV.'Dr Hamish Meldrum, Chairman of Council, BMA, 2011.
Development and design sponsored by Bristol-Myers Squibb (BMS). Printing supported by ViiV Healthcare UK Ltd.
Neither BMS nor ViiV have had any editorial input or control over the content of this booklet.
Medical Foundation for AIDS & Sexual Health (MedFASH) 2011. All rights reserved. No part of this publication may be reproduced without the prior written permission of the publisher. This publication is available to download free from our website. Hard copies can be purchased by contacting us at the address below. ISBN 978-0-9549973-9-7 a charity supported by the British Medical Association Medical Foundation for AidS & Sexual Health (MedFASH)BMA House, tavistock Square, London, Wc1H 9JPtel: 020 7383 6345 Fax: 0870 442 1792email: enquiries@medfash.bma.org.ukwww.medfash.org.uk

Source: http://www.medfash.org.uk/uploads/files/p17abjng1g9t9193h1rsl75uuk53.pdf

Bo-1ra-leg-13-10

DE LA REPUBLICA ARGENTINA BUENOS AIRES, VIERNES 11 DE MAYO DE 2001 Los documentos que aparecen en el BOLETIN OFICIAL DE LA REPUBLICA ARGENTINA serán tenidos por Nº 29.646 auténticos y obligatorios por el efecto de esta publicación Y AVISOS OFICIALES y por comunicados y suficientemente circulados dentro de todo el territorio nacional (Decreto Nº 659/1947)

Dopage et chiralité

Exemple d'activités de classe Dopage et chiralité Préambule Extrait du programme d'enseignement spécifique de physique-chimie de la série scientifique en classe termin) Structure et transformation de la matière Notions et contenus Compétences exigibles Représentation spatiale des molécules