***************************** #ChangeTheFaceOfHIV GP Learning Module: Part A Val’s story ***************************** UK/HIV/0036/16a(2), March 2017

GP Learning Module (Part A) #ChangeTheFaceOfHIV GP Learning Module (Part A) ************************************************************************** The following RCGP accredited two-part learning module is designed to train and support GPs in offering HIV testing to patients Learning objectives for module Part A: Increase recognition of the signs and symptoms of HIV Increase understanding of why and when to offer an HIV test Understand some of the common concerns GP have around HIV testing and how these can be addressed Educate on the importance of early diagnosis and the impact of late diagnosis - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

********************************************* Val’s story ********************************************* Val is a 50 year-old school teacher of UK origin and lives with her partner of eight years. She has been presenting with tiredness, feeling run down and night sweats for the past 8 months and seen various GPs at the surgery. 1 of 2 cont. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

********************************************* Val’s story ********************************************* At her latest visit, you question her about the regularity of her periods and suspect she may be going through menopause. She says her periods are still regular and normal. You take a full blood count, test her thyroid function and do a follicle stimulating hormone (FSH) and oestradiol test, all come back normal. What else would you do? 2 of 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Are you considering HIV at this point? *************************

****************************************************** “It’s not my job as a GP” ****************************************************** Up to 75% of people diagnosed late will have seen their GP in the 1-3 years leading up to diagnosis… often with signs and symptoms of HIV1,2 The majority of people with undiagnosed HIV commonly present to primary care1 References: Burns F et al. (2008). Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 22(1):115-22. Dorward J et al. (2012). Opportunities for earlier diagnosis of HIV in general practice. Sex Transm Infect. 2012;88:524. ****** ******

********************************************* Val’s story ********************************************* Six months later Val returns with shingles. She’s been off work for a number of days and still feels extremely tired and run down. You ask her about her work patterns and lifestyle and she says she’s been very busy at work and, as a result, is working long hours. You recommend her to take it easy and prescribe aciclovir to treat the shingles. What else would you do? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Have you considered HIV yet? *************************

What has stopped you offering Val an HIV test? *************************

1. 2. 3. “I’m not sure what to look out for” THERE ARE THREE STAGES OF HIV INFECTION1,2: *************************************************************************** Primary infection (seroconversion) First 1-4 weeks post exposure, typically associated with flu-like or glandular fever-like symptoms. 1. Asymptomatic stage (post-seroconversion) Many people start to feel better and some may live symptom-free, this can last up to 10 years. Over time significant immunological damage will result. 2. References Terrence Higgins Trust. (2016). Stages of HIV infection. Available at: http://www.tht.org.uk/myhiv/HIV-and-you/Simple-science/Stages-of-hiv-infection. [Accessed: July 2016]. AVERT. (2015). Symptoms and stages of HIV infection. Available at: http://www.avert.org/about-hiv-aids/symptoms-stages. [Accessed: July 2016]. Symptomatic stage During this stage there is usually a lot of damage to the immune system. Now, people are much more prone to serious, ‘opportunistic’ bacterial and fungal infections that a healthy person would be able to fight off.. 3.

“I’m not sure what to look out for…” ******************************************************** Think about testing for HIV as part of your differential diagnosis when: A patient presents with these signs or symptoms: e.g. weight loss, herpes, persistent diarrhoea, oral thrush, glandular fever-like symptoms1 If you don’t know the cause for the patient’s presentation, or When you are considering a blood test for any other reason 1. Damery S., et al. Assessing the predictive value of HIV indicator conditions in general practice: a case–control study using the THIN database. Br J Gen Pract. 2013 Jun; 63(611). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662453. [Accessed: October 2016].

“I’m not sure what to look out for…” ******************************************************** The risk of underlying HIV is higher if: These signs and symptoms are unusually severe or recurring They are difficult to treat DON’T THINK TWICE, THINK TEST

********************************************* Val’s story ********************************************* Another 4 months later, Val returns. She’s had diarrhoea for 2 weeks and is growing frustrated as she’s taken a lot of sick days from work in the past six months. You ask her about any recent foreign travel, but she’s not been away. 1 of 2 cont. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

********************************************* Val’s story ********************************************* You’re getting more concerned about her health. You order a test for her liver function and another full blood count and send off stool samples. You prescribe her anti-diarrhoeal medication to treat the diarrhoea What else would you do? 2 of 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

************************* Will you consider adding an HIV test to the mix of tests you are ordering? *************************

I’m worried about her reaction ************************************************************************** There’s often a discrepancy between GPs’ perceived patient acceptability and real-life patients’ attitudes to being offered a test Research has shown that the majority of patients are happy to be offered an HIV test in primary care and would react positively to the offer, even when they are not expecting it1 References 1. Rayment M, Thornton A, Mandalia S, Elam G, Atkins M, Jones R, et al. (2012) HIV Testing in NonTraditional Settings – The HINTS Study: A MultiCentre Observational Study of Feasibility and Acceptability. PLoS ONE 7(6): e39530. doi:10.1371/journal.pone.0039530 1 of 2 cont. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

I’m worried about her reaction ************************************************************************** If a patient reacts negatively or has any concerns, it’s important to normalise the offer, explain why you’re offering and reassure them on any of their specific concerns 2 of 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

“I don’t have time to offer the test” ******************************************************************************** Offering an HIV is simple and straightforward, and won’t take up much of your time Offer the test as part of differential diagnosis – as you would with any other test No need for sexual history taking No need for lengthy pre-test counselling And… as with any other test, there is no need for written consent, verbal is sufficient With one simple blood test, we can make all the difference - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

********************************************* Val’s story ********************************************* Test results reveal mild elevation of liver transaminases. Since the tests, Val has had no response to the anti-diarrhoeal medication. She returns to the practice 3 weeks later looking very unwell and reveals she has lost 8kg in the last 2 months. You send a referral letter to your local GI department requesting further investigation. An appointment is arranged for 6 weeks time. 1 of 3 cont. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

********************************************* Val’s story ********************************************* Another 3 weeks pass, Val has developed a persistent dry cough and marked breathlessness on exertion. Her partner grows increasingly concerned about her state and takes her to A&E on a Sunday when she is really struggling. 2 of 3 cont. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >

********************************************* Val’s story ********************************************* The doctor in A&E arranges an X-ray and she is admitted to the respiratory ward and diagnosed with pneumocystis pneumonia (PCP). An HIV test is also ordered. She tests positive for HIV and her CD4 count is 100 cells/mm3.* She has late stage HIV. *A normal CD4 count is between 500 – 1500 cells/mm3 1 References: 1. WebMD. (2016). HIV, AIDs, and the CD4 count. Available at: http://www.webmd.com/hiv-aids/cd4-count-what-does-it-mean. [Accessed: July 2016]. 3 of 3 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

You get a communication from the local hospital to let you know that Val has HIV ************************************************************************

The many missed opportunities ***************************************************************** With no apparent risk factors to suggest a significant probability of HIV infection, and with such an insidious onset, the diagnosis eluded many practitioners until Val was seriously ill Remember, some people with HIV have no obvious risk factors for HIV infection These are the ones that can go on to develop complex comorbidities

New recommendations for GP surgeries in high prevalence* areas NICE HIV testing guideline 2016 ***************************************************************** New recommendations for GP surgeries in high prevalence* areas Offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who: is undergoing blood tests for another reason and has not had an HIV test in the previous year [new 2016]1 References National Institute for Health and Care Excellence (NICE), 2016. HIV testing: increasing uptake among people who may have undiagnosed HIV. London: NICE. *Local authorities with a diagnosed HIV prevalence of 2 or more per 1,000 people aged 15 to 59 years.

NICE HIV testing guideline 2016 ***************************************************************** New recommendations for GP surgeries in extremely high* prevalence areas Consider HIV testing opportunistically at each consultation (whether bloods are being taken for another reason or not), based on clinical judgement [new 2016]1 References National Institute for Health and Care Excellence (NICE), 2016. HIV testing: increasing uptake among people who may have undiagnosed HIV. London: NICE. *Local authorities with a diagnosed HIV prevalence of 5 or more per 1,000 people aged 15 to 59 years.

************************************** HIV testing is a simple intervention that can save lives. With one simple blood test, we can save lives and improve patients’ health outcomes. DON’T THINK TWICE, THINK TEST. ************************************** #ChangeTheFaceOfHIV