3Cs & HIV programme Basic sexual health training for GP staff [INSERT PRESENTER NAME]

Aim of session Raising awareness of why and how to test for HIV in primary care 2

Outline HIV epidemiology in the UK Why focus on HIV testing? Data relevant to [local area] HIV testing in the UK Practicalities of HIV testing 3

4

Annual new HIV and AIDS diagnoses and deaths: UK,

6 Time course of HIV infection

HIV treatment HAART (highly active antiretroviral therapy) – emerged in 1996 and has revolutionised the care of HIV Lifespans are typically near normal in individuals diagnosed with early stage HIV Treatments better tolerated with lower pill burdens 73Cs & HIV Training

HIV treatment (cont.) Antiretroviral drugs belonging to several classes NRTI, Nucleoside reverse transcriptase inhibitor NNRTI, Non-nucleoside reverse transcriptase inhibitor PI, protease inhibitor INI, Integrase inhibitor CCR5 antagonist / Entry inhibitor 8Source: BHIVA guidelines for the treatment of HIV-1-positve adults with antiretroviral therapy 2012

Prevalence of HIV in the UK Estimated 96,000 (90, ,500) people in the UK living with HIV −24% (18%-30%) unaware of their infection National prevalence is estimated 1.5 per 1,000 population, but much higher in some communities −47 per 1,000 in men who have sex with men (MSM) (nearly 5%) −37 per 1,000 among black Africans (nearly 4%) HIV prevalence is significantly higher in London than elsewhere −Most deprived areas have the highest prevalence, especially in London. 9Source: HPA 2012 HIV In the United Kingdom Report

New HIV diagnoses in the UK, ,280 people were newly diagnosed with HIV in the UK. −Highest number for MSM (3,010) −52% of heterosexuals probably acquired their HIV infection in UK Half of these (47%) were diagnosed late, and should have been on treatment (CD4 <350) A quarter (26%) were diagnosed very late, i.e. diagnosed with AIDS (CD4 <200) People diagnosed late have a higher mortality and morbidity, risk of transmission and costs of care 10Source: HPA 2012 HIV In the United Kingdom Report

Why focus on HIV testing? Being diagnosed late has a major impact on people’s prognosis 1 There is less transmission of HIV from those who know about their infection, with public health impact on the population 2,3,4 People being diagnosed earlier would lead to cost savings for the NHS 5 There are missed opportunities to diagnose in primary care HPA 2012 HIV In the United Kingdom Report 2 Sanders, G. et al Fox J et al HIV Med (2009) 4 Cohen MS et al N Engl J Med 2011; 5 Krentz et al HIV Med 2008; 6 Burns, FM et al. AIDS (2008)

HIV data for [Local Authority] 12 Prevalence of diagnosed HIV −Number if > 5 −X.X per 1,000 population: High/low prevalence area −In local middle super output area (MSOA), prevalence is X.X/1,000 Number new diagnoses ( ) −XXX new HIV diagnoses Proportion late HIV diagnoses: −XX% diagnosed with CD4 <350 −XX% diagnosed with CD4 <200 Local HIV service −XXXXXXXXXXXXXXXXX −Lead clinician For local adaptation

National HIV testing guidelines endorsed by National Institute of Health and Clinical Excellence (NICE) and RCGP 1 Routine offer and recommendation of HIV test: 1. Specialist services 2. Patients at higher risk 3. Patients with clinical indicator diseases 4. Geographic targeting 1 BHIVA/BASHH/BIS. UK national guidelines for HIV testing BHIVA/BASHH/BIS. UK national guidelines for HIV testing (2008) National HIV testing guidelines

Specialist services:STI clinics, antenatal, termination of pregnancy, drug dependency services and clinical services for patients with tuberculosis, HBV, HCV and lymphoma Patients at higher risk:Partners of high risk individuals (HIV-positive, MSM, IDU), from a high prevalence country, MSM, reporting history of IDU and diagnosed with an STI Patients with clinical indicator diseases: List of over 52 clinical diseases indicative of adult HIV infection Geographic targeting:In areas of high diagnosed HIV prevalence (>2/1, year olds) all new patient registrants in primary care 1 BHIVA/BASHH/BIS. UK national guidelines for HIV testing BHIVA/BASHH/BIS. UK national guidelines for HIV testing (2008) National HIV testing guidelines (cont.)

Routine HIV offer at new registration in primary care 2010: eight pilot projects evaluating expanded HIV testing models, in general medical services in high prevalence areas (three primary care) 1 Pilot projects demonstrated: −High levels of acceptability among patients −Feasibility of routine testing in different medical services −6 of 8 projects exceeded cost-effective threshold of 1 new positive case per 1,000 tests 151. HPA Time to test for HIV report (2011) HIV high prevalence area slide

Results of primary care pilot projects 1 3Cs & HIV Training HPA Time to test for HIV report (2011) London (Lewisham) Setting: 18 of 48 practices Method: Routine offer to18-59 year olds New patient health check INSTi® test Results: 62% uptake (2,700 patients tested) 19 positives (7/1,000) West London Setting: 1 practice Method: Routine offer to year olds Offered to all patients on list of 3/4 GPs Saliva tests Results: 67% uptake (1,000 patients tested) 0 positives Brighton & Hove Setting: 10/26 practices with LES Method: Routine offer to year olds New patient health check INSTi® test Results 59% uptake (1473 patients tested) 2 positives (1.4/1,000 ) HIV high prevalence area slide

Test acceptability in general practice patients 3Cs & HIV Training 17 HIV high prevalence area slide

Patients with clinical indicator diseases 52 conditions associated with adult HIV infection: AIDS defining illnesses (e.g. Tuberculosis, Kaposi’s sarcoma, cerebral toxoplasmosis) Indicator conditions: illnesses where HIV test offer recommended 1 include: −Bacterial pneumonia −Peripheral neuropathy −Severe/recalcitrant seborrhoeic dermatitis or psoriasis −Mulidermatomal/recurrent herpes zoster −Oral candiasis −Chronic diarrhoea of unknown cause −Lymphadenopathy of unknown cause −STIs −Pyrexia of unknown origin 18 1 Arkell et al. British Journal of General Practice 2011.

Mononucleosis-like syndromes 19Image from (accessed May 2012) Glandular fever-like illness Sore throat Diarrhoea Headaches Generalised macular rash Lymphadenopathy Serology may be negative

HIV in patients with infectious mononucleosis Infectious mononucleosis associated with high prevalence (>0.1%) of undiagnosed primary HIV infection A study 1 carried out anonymous HIV testing of samples from primary care in SE London submitted for a glandular fever (GF) screen High prevalence of HIV among these (1.3%;11/857) 73% (8/11) were not tested at initial primary care presentation or after window period Missed opportunities to diagnosed primary HIV infection 201. Hsu, D et al. HIV Medicine (2012)

Herpes zoster virus 21Image from (accessed May 2012)

Oral candidiasis associated with erythematous candidiasis 22Image from (accessed May 2012)

Severe/recalcitrant seborrhoeic dermatitis 23Image from (accessed May 2012)

Type of HIV test 24 Serology: −All (>99%) use 4 th generation assay (detects antibody and antigen) −Short window period (~4 weeks) −Can be requested with other tests Point of Care Test (POCT): −Oral swabs or finger-prick −Usually 3 rd generation test (detects antibody) so longer window period (~12 weeks) −Provide immediate (<15minutes) results −Lower positive predictive value in low prevalence population (i.e. in general practice) −Results reported as “reactive” and must be confirmed

Patient acceptability Normalise testing: If indicated, recommend HIV test and advise can be done as part of routine bloods to investigate current problem Cree VE. Waverley Care African Health Project – Final Report Madge S et al. HIV in Primary Care. Medical Foundation for AIDS & Sexual Health (MedFASH) “All those interviewed saw the GP as the central person in their healthcare, and none felt it would be inappropriate for the GP to invite them to have an HIV test” Feedback from survey of African population in Glasgow 1

Discussion What might make you hesitate from raising the HIV test in a discussion with a patient? 26

HIV testing – myth busting 271. Madge S et al. HIV in Primary Care. Medical Foundation for AIDS & Sexual Health (MedFASH). 2011

Some useful phrases 28More phrases available from MedFASH: HIV in Primary Care 2011

Normalising the offer Can use: Computer prompts Add to lab forms Posters (staff and patients) Reception cards 29

The HIV care pathway in [local area] For clinical advice and support, contact: [Name(s), contact details including bleep number] Sample referral pathway provided 3Cs & HIV Training 30 For adaptation per centre

Giving an HIV positive/reactive result 1 Face to face in a confidential environment and in a clear and direct manner. o Have translation services available if needed Ensure there is a clear pathway for onward referral o Individuals are seen by an HIV specialist preferably within 48 hours and certainly within 2 weeks Detailed post-test discussion by the GUM/HIV specialist team o Including assessment of disease stage, consideration of treatment, and partner notification 311.BASHH/BHIVA/BIS UK National HIV Testing Guidelines

HIV positive/reactive results Remember… The situation for people with HIV in the UK is much more optimistic than it was 20 or even 10 years ago Knowledge of HIV status allows access to appropriate care 1 People diagnosed early can now live near-normal lifespans 2 With successful treatment, onward transmission is reduced Baggaley, R. HIV for non-HIV specialists - diagnosing the undiagnosed. MedFASH Health Protection Agency. HIV in the United Kingdom: 2011 Report 2. Madge S et al. HIV in Primary Care. Medical Foundation for AIDS & Sexual Health (MedFASH). 2011

Giving an HIV negative result If the test result is negative outside the window period The patient can be reassured that they do not have HIV There is an opportunity to discuss on-going risk and risk reduction Information can be provided about avoiding HIV acquisition Printed “FAQ” hand-outs can be useful to address questions, concerns and local HIV and sexual health service support. 331.BASHH/BHIVA/BIS UK National HIV Testing Guidelines

Further resources Think! Test for HIV: (includes film clips) HIV in Primary Care: Tackling HIV testing: resource-packhttp:// resource-pack E-learning Introductory Certificate in Sexual Health: cert_in_sexual_health.aspx cert_in_sexual_health.aspx 34

Support from Name: [your name here] [your address here] Phone number: [your phone number here] Thank you. 35

Acknowledgments Catherine Howland, Bristol-Myers Squibb (Think! Test for HIV) Dr Ann Sullivan, Consultant Physician, Chelsea & Westminster Hospital Professor Jane Anderson, HIV Consultant, Homerton University Hospital and Public Health England Professor Chris Griffiths, Dr Werner Leber, Ms Heather McMullen, Centre for Primary Care and Public Health; Queen Mary University London, on behalf of the RHIVA 2 Study Group. 36