The case for HIV testing A presentation for the clinical team in your practice Preparation for teaching: Choose/agree a time and date for your 20-30 minute session and invite your clinical team members. Make sure you will have access to PowerPoint and a projector (or a big enough computer screen for your team to see well). Read and, perhaps, print out these teaching notes. What you choose to do will probably depend as to how confident/experienced you are as a teacher of groups. Make sure you know how to use ‘Slide Show’ and how to advance the slides Your clinical team need to be ready to work in pairs. On the day make sure you have: enough chairs some pens and A4 paper a flip chart

Why test for HIV? Work in pairs Try to think of at least two reasons why it is good practice to offer HIV tests AIM: To get your clinical team to focus on what they know (and don’t know!) about banner headline aspects of HIV. This should help their engagement in subsequent information-giving. This should be a SHORT task (2 or 3 minutes) Teaching notes: Try and get the pairs to mix doctors and nurses as far as possible. Don’t take feedback at this stage

Annual new HIV and AIDS diagnoses and deaths: UK, 1981-2012 Graph kindly provided by Public Health England ART available HIV test developed Teaching notes: AIM of this slide and the following one: To reflect hard on, and learn about, HIV, AIDs and HIV death rates in the UK over time. This first slide just shows numbers of newly diagnosed with HIV in the UK, let them absorb it. BEFORE THE NEXT SLIDE do this 3 minute exercise Ask your team to make a crude copy of the red line on their paper – one sheet per pair would be fine if they want to collaborate! “just have a guess, you won’t have to share your efforts if you don’t want to!” Ask them to have a guess and draw two additional lines: AIDS diagnoses Deaths due to HIV This is hard – ask if anyone is ‘brave enough to hold up their graph’? Move on to next slide which reveals all….

Prevalence of HIV in the UK 2012 An estimated 98,400 people were living with HIV. The overall prevalence is 1.5 per 1,000 population 22% were unaware of their infection. Prevalence much higher in some communities 47 per 1,000 among men who have sex with men (MSM) 37 per 1,000 among black Africans HIV prevalence continues to be significantly higher in London than elsewhere in the UK. The most deprived areas have the highest prevalence, especially in London. Teaching notes The proportion undiagnosed HIV is slowly dropping. HIV is, increasingly, a disease of poverty. In LONDON the number of men who have sex with men who are thought to be infected is thought to be nearer 85/1000 – 32/1000 outside London Answers to common questions that may come up: For many years a range of methods have been used to estimate the rates of undiagnosed HIV (for example through studies that screen samples that have been collected for other reasons, such as FBCs in some hospitals and also ANC samples). In the UK, injecting drug use is not nearly such a big factor for transmission as in some other countries (notably some Eastern European countries). – See next slide

New HIV diagnoses by exposure group: United Kingdom, 2002 – 2012 New HIV diagnoses by exposure group: United Kingdom, 2002 – 2012 * *Data have been adjusted for missing exposure information Teaching notes Check everyone orientated – this is a slide based on the last decade or so. HIV infections acquired through heterosexual contact have account for just under 3000 (just under 50%) of all diagnoses in 2011 (TOTAL heterosexual, ie blue plus grey line, above) Among men who have sex with men (MSM), the number of new HIV diagnoses have surpassed those made among heterosexuals for the first time since 1999, accounting for just over 3000 of all new diagnoses made in 2011 (green line). Infections acquired through injecting drugs and through other routes have remained low over time, accounting for 140 new diagnoses each in 2011.

What is late diagnosis?

Association between virological, immunological, & clinical events and time course of untreated HIV (Reproduced with permission from e-GP: e-Learning for General Practice, RCCP) Teaching notes Make sure you understand this graph yourself and consider how to talk it through. To understand late diagnosis, your team need to understand the ‘natural history’ of HIV infection. The viral load (green line and writing), is a measure of the amount of HIV in the blood. Viral load can measure from ‘undetectable’ (below 50 copies/ml) to over a million copies/ml. The CD4 cell count (blue line and writing), gives a good idea of how damaged the immune system is. A LOW CD4 count leaves you vulnerable to certain infections and tumours. The black sub headings are important – Primary infection, asymptomatic and symptomatic: draw attention to these. In healthy non-HIV infected individuals the CD4 count is usually above 500 cells/mm3, although some healthy people will have lower counts. HIV positive people with a good CD4 count (350 and above, and depending on other clinical factors) are not currently offered treatment, they will simply be monitored. HIV positive people with a CD4 count below around 200-300 cells/mm3 are at risk of developing HIV-related opportunistic infections and tumours (but some may not have significant symptoms). 7

Late diagnosis Defined by who should have started treatment already. ie when CD4 count below 350 cells/mm3 In 2012, 47 % of adults diagnosed in the UK were diagnosed late They were ten times more likely to die within a year of diagnosis Also higher risk of permanent disability Acute serious illnesses Slower response to treatment Onward transmission of infection Teaching notes These points will come up one by one. Make sure you are familiar with this slide and can talk it through 8

Teaching notes This- and the following slide - is a graphical take on some of the info given on the previous slide. Make sure you understand it yourself beforehand This (first) slide shows this for those diagnosed promptly (ie when their CD4 count was still above 350) Their numbers are shown by the blue bars Draw attention to the red line – ‘short term mortality’ - this is the percentage of patients known to have died within a year of diagnosis. You can see that relatively few die within a year of diagnosis (red line) But have a look now at how this compares to those diagnosed LATE (ie a CD4 count below 350)…see next slide….

Teaching notes The new, right hand side, of this graph shows that the numbers diagnosed at a late stage were HIGHER than those diagnosed in a timely fashion (though the situation is improving). The MUCH HIGHER red line shows that a much higher proportion of those diagnosed late die in the 12 months after diagnosis – ie they were diagnosed TOO late to do them any good. => It is much better to diagnose HIV early than late (just like cancers…)….lives can be saved by HIV testing

Late diagnoses of HIV by exposure group: United Kingdom, 2011 Teaching notes Make sure you understand this graph yourself, which is revealed in 3 stages. This slide shows stage I The right hand column shown here gives the overall picture. Ie – overall – 47% of people are diagnosed late Ask your group whether they think the other groups (listed across the bottom) will each be diagnosed LATER than the overall average or EARLIER If you have time, they could discuss this in pairs. You can take feedback and ideas from them – when they give you feedback it is sometimes worth saying ‘why did you decide that?’ once you click to the next slide, the answers are given……

Late diagnoses of HIV by exposure group: United Kingdom, 2011 Teaching notes This slides gives them the teaching question Ask your group whether they think the other groups (listed across the bottom) will each be diagnosed LATER than the overall average or EARLIER If you have time, they could discuss this in pairs. You can take feedback and ideas from them – when they give you feedback it is sometimes worth saying ‘why did you decide that?’ once you click to the next slide, the answers are given……

Late diagnoses of HIV by exposure group: United Kingdom, 2011 Teaching notes Now you can give them the answers Congratulate them if they had arrived at pretty much the right conclusions Note that male heterosexuals and female heterosexuals are the most likely to be missed, ie diagnosed late Ask your group why they think that is the case. Probably: Men who have sex with men have good awareness and good access to testing Heterosexual women are routinely offered tests antenatally Male heterosexuals may not be seen as at risk and may interact less with health services than their female counterparts (who are having smears, contraception, babies etc).

Trends in late diagnosis (CD4<350) by exposure group: UK, 2002-2011 Over the last decade, the proportion of individuals diagnosed late has declined significantly, from 60% in 2002 to 47% in 2011 (p<0.0001 for trend), and across all exposure groups. In primary care we can help this trend improve / accelerate by being much more proactive about HIV diagnosis – ie doing a lot more testing. The HIV TIPs website is full of ideas to help you increase your testing rate.

Now add to your list Can you think of any more reasons that it is good practice to test for HIV? Add them to your list Encourage your group to think of additional reasons it is good to test for HIV Some examples of reasons to test given below HIV infection responds well to treatment But late diagnosis is harmful to health so we need to get testing / diagnose it as early as possible Once we have detected HIV infection in a patient, there is a better chance of preventing transmission on. (the short answer is to diagnose HIV as early as possible – ie in asymptomatic – and not wait for symptoms, as you may save a life. BUT if symptoms are present then best respond to them quickly rather than wait, so again testing is good. ‘If in doubt, test!

Choose 3 to 6 key facts on HIV What would you want a receptionist to know? What would you want patients to know? Make a list on the flip chart Discuss and agree how you would like to circulate this To your team? To your patients? Who is responsible? / completion date Ask your clinical team what the main messages would be for non clinical team members and patients Likely to be simple things like: - HIV is very responsive to treatment - The problem only comes if people don’t know they have HIV - Therefore encouraging HIV testing is a very good thing and may save lives But more complex or sophisticated points are also welcome Now decide how you plan to circulate those simple messages within the whole team Do you want to give those messages to your patients too? If so how?

Use HIV testing You might save a life!