Dr Renos Ioannou GPST2 NHS Lothian Influenza, Pneumococcal and Hepatitis B vaccine uptake in HIV positive adults attending the Infectious Diseases Unit in Edinburgh Dr Renos Ioannou GPST2 NHS Lothian WGH RIDU Audit/QIP Scottish HIV & AIDS Group Meeting - 8th September 2017

Background Annual influenza, pneumococcal and Hep B immunisation is recommended for all HIV positive adults in the UK[1] However, HIV services do not receive specific funding to provide immunisations Influenza is an important cause of morbidity in HIV positive adults[2] Streptococcus pneumoniae infection is a predominant cause of bacterial infection. The incidence of IPD has declined with effective ART but HIV- positive remain at an approximately 40-times higher risk of disease[3] There is limited information on correlates of immunity to HBV vaccination in HIV positive population but co-infected persons show increased rates of progression to cirrhosis and liver cancer and a higher mortality[4] Geretti AM et al. British HIV Association Guidelines on the Use of Vaccines in HIV-Positive Adults 2015. HIV Med. 2016;17 Suppl 3:s2-s81. Remschmidt C et al. Influenza vaccination in HIV-infected individuals: systematic review and assessment of quality of evidence related to vaccine efficacy, effectiveness and safety. Vaccine. 2014;32(43):5585-92. van Hoek AJ, Andrews N, Waight PA et al. The effect of underlying clinical conditions on the risk of developing invasive pneumococcal disease in England. J Infect 2012; 65: 17–24. Martín-Carbonero L, Poveda E. Hepatitis B virus and HIV infection. Semin Liver Dis 2012; 32: 114–9

Methods Objective: to determine the uptake/documentation of Influenza, Pneumococcal and Hepatitis B vaccination in our HIV cohort Cross-sectional retrospective study All patients who attended HIV OP clinics over 2 weeks period in Nov 2016 (21/11/16 - 02/12/16) at WGH identified from the HIV database Demographics, biochemical, virological and vaccination data were collected from the HIV database If data was not available or dubious, further information was taken from the electronic clinic notes (TRAK), TRAK results and APEX if not available on TRAK

Demographics Characteristic (Total = 102) Median age 49 (23 - 69) Sex (M/F) 66 (65%)/36 (35%) Ethnicity White Sub-Saharan Africa Other 8 (8%) Median CD4 count (cells/cm3) CD4 < 100 1 (1%) % of patients with VL <40 c/ml 91 (89%)

Influenza Vaccination Flu vaccination Total n = 102 Vaccinated 58% (59) Yearly Vaccinated (since 2011) 7% (7) Not Vaccinated Declined Unwell Year Abroad 1% (1) Not documented 34% (35)

Pneumococcal Vaccination Total n = 102 Vaccinated within last 5 years PCV13 (Prevnar) PPV-23 (Pneumovax) Both Not Known 2% (2) Not Vaccinated Declined 2% (2) Pentennial Vaccination 7% (7) Overdue 3% (3) Not documented 58% (59)

Hepatitis B Serology Hep B status Total n = 102 HBsAg Positive 2% (2) anti-HBc Positive Antibody response >10 Negative Not checked 8% (8) anti-HBs >100 10 < anti-HBs < 100 <10 25% (25)

HepB Vaccine Response (anti-HBc+) anti-HBs >10 Total n = 11 > 100 Achieved with 3 doses With a booster/3 doses + booster Partial Documentation/< 3 Doses No Documentation 91% (10) 10 < anti-HBs < 100 0% (0) anti-HBs < 10 Total n = 6 3 Doses +booster < 3 Documented Doses 100% (6)

Hep B Vaccine Response (anti-HBc -) anti-HBs >10 Total n = 32 > 100 Achieved with 3 doses With a booster/3 doses + booster Partial Documentation/< 3 Doses No Documentation 38% (12) 10 < anti-HBs < 100 3 Doses Booster/3 Doses +booster < 3 Documented Doses 13% (4)

Hep B Vaccine Response (anti-HBc -) anti-HBs <10 Total n = 23 3 Doses Booster/3 Doses + Booster < 3 Documented Doses No Documentation 57% (13) 23% (14/62) of the anti-HBc negative cohort had anti-HBs <10 and no documented Hep B vaccinations

Summary 58% of the cohort received Influenza vaccine, with 7% receiving yearly since 2011 40% received pneumococcal vaccine Less than 5% declined vaccination 31% of the cohort achieved anti-HBs >100 29% of the cohort susceptible to Hep B At least one patient from this cohort was admitted with pneumonia. One patient died and another one was admitted due to comorbidities 4 patients (4%) received vaccines at the GP practice (based on the clinic notes) Patients reviewed by the specialist HIV nurses had good immunisation documentation. Some consultants write the immunisation history at the top of every clinic letter

Limitations We relied on what was recorded in the electronic notes regarding offering vaccinations Database vaccinations have only been recorded from 2002 onwards 33% of patients have been attending the clinic for < 5 years and many of them transferred from different clinics, 44% (11/25) of the electronically unavailable anti-HBs belong to this cohort

Further Plans Finding ways to improve documentation and communication routes Possibility of checklist for annual review? Possibility of automatic reminders on the database? Discussion: ? encouraging patients to be reviewed by specialist nurses at least once a year (nurses now are updating the database when vaccinating) ? best practices from other centres ?what’s really feasible for the patients’ GP vs HIV OP Can anyone remember any new HBV infection in the HIV population? Benefit of TDF as PREP

Thanks Dr Muge Cevik Prof Clifford Leen Linda Panton Dr David Wilks