BHIVA Audit and Standards

1. BHIVA Audit and Standards Overview of standards project Survey of management of cardiovascular risk Preliminary findings of mortality audit

2. Overview of Standards Project • Aim: • To produce an independent report which recommends standards for health services for people with HIV in the UK and which has broad support among clinicians, NHS management and representatives of communities affected by HIV/AIDS.

3. Scope of project • Concise, prescriptive, independent standards • Organisation of out-patient and in-patient care for adults with HIV • Service networks and referral pathways based on patient groups defined by care needs • Level of provision and timely access to specific facilities • Roles and staffing levels.

4. Issues for the standards project • Co-branding with Royal College of Physicians • Wide consultation and stake-holder engagement. • Operations group reporting to BHIVA Executive and Standards and Audit Sub-Committee: Margaret Johnson, Celia Skinner, Colm O’Mahony, Rosy Weston, Gus Cairns, Paul Ward. • Project team: Hilary Curtis (manager), Sally Beckwith (researcher).

5. How you can help • Hilary and Sally are here and would like your input: • Please have a chat with them, at the standards project stand or anywhere at the conference • Please complete brief questionnaire mapping current provision.

6. Survey of management of cardiovascular risk factors in HIV patients • Responses were received from 137 clinical centres: • 79% outside NHS London region, 18% in London region, 3% not stated • 42% serving 0-100 HIV patients, 38% serving 101-500, 17% serving more than 500, 2% not stated.

7. What guidelines do you follow when managing cardiovascular risk in HIV patients? Percent of respondents NB respondents could select more than one set of guidelines.

8. 100% 80% Not stated 60% None Limited 40% Good 20% 0% Exercise classes Dietician Smoking Lipid specialist Diabetes cessation service specialist What level of access do you have to the following services? Percent of respondents

9. Which of the following form part of your baseline assessment when seeing a newly diagnosed HIV positive patient? Percent of respondents

10. Which of the following form part of your routine assessment before starting a patient on ART? Percent of respondents

11. How frequently do you measure the following in patients on ART? Percent of respondents

12. When starting patients on ART, to what extent is your choice of drugs affected by theindividual patient's cardiovascular risk profile?

13. Intervention in HIV patients with raised lipids • 85% of respondents rated overall risk of cardiovascular event as the most important factor in deciding whether to intervene. • Only 35% and 23% respectively specified fasting triglyceride and total cholesterol thresholds at which to intervene if modifiable risk factors had already been addressed.

14. 60% 50% 40% 30% 20% 10% 0% 2-4 4-6 6-8 8-12 >12 4.0 >5.0 >6.0 >7.0 >8.0 Intervention thresholds Among the minority of respondents who did specify thresholds, these were as follows: Percentage of respondents mmol/l Fasting triglyceride Total cholesterol

15. 39% 3TC/FTC + TFV 36% ABC + 3TC 12% 3TC + ZDV 47% EFV 23% NVP 9% ATZ boosted 9% ATZ unboosted 1% FosAPV 0% LPVr Illustrative scenario 1: starting ART in patient at high CHD risk Preferred initial therapy for a 50 year old African male newly presented with HIV infection, with BMI 33 kg/m2; family history of hypertension and diabetes; long term heavy smoker; CD4 count 150; TC 8.0 mmol/l; TG 2.7 mmol/l; HDL 1.25 mol/l; fasting glucose 6.5 mmol/l: Note: similar results were obtained for the same question when asked as part of pilot test of online survey software, open to all UK/ROI HIV physicians to respond.

16. Nil Change ART Statin Fibrate Omega-3 Refer Not stated F- EFV 0% 20% 40% 60% 80% 100% Illustrative scenario 2: managing elevated lipids Preferred management of a patient with a TC of 8.5 mol/l and triglyceride of 6.0 mol/l - modifiable risk factors already addressed and with no concerns about CD4, VL, toxicity, intolerance or inconvenience. F- = white female aged 30 with negative CHD family history on TFV/3TC.

17. Nil Change ART Statin Fibrate Omega-3 M++ EFV Refer Not stated F- EFV 0% 20% 40% 60% 80% 100% Illustrative scenario 2: managing elevated lipids Preferred management of a patient with a TC of 8.5 mol/l and triglyceride of 6.0 mol/l - modifiable risk factors already addressed and with no concerns about CD4, VL, toxicity, intolerance or inconvenience. F- = white female aged 30 with negative CHD family history on TFV/3TC. M++ = Asian male aged 50 with NIDDM and positive CVD family history on TFV/3TC.

18. Nil Change ART F- LPVr Statin Fibrate Omega-3 M++ EFV Refer Not stated F- EFV 0% 20% 40% 60% 80% 100% Illustrative scenario 2: managing elevated lipids Preferred management of a patient with a TC of 8.5 mol/l and triglyceride of 6.0 mol/l - modifiable risk factors already addressed and with no concerns about CD4, VL, toxicity, intolerance or inconvenience. F- = white female aged 30 with negative CHD family history on TFV/3TC. M++ = Asian male aged 50 with NIDDM and positive CVD family history on TFV/3TC.

19. Illustrative scenario 2: managing elevated lipids Preferred management of a patient with a TC of 8.5 mol/l and triglyceride of 6.0 mol/l - modifiable risk factors already addressed and with no concerns about CD4, VL, toxicity, intolerance or inconvenience. F- = white female aged 30 with negative CHD family history on TFV/3TC. M++ = Asian male aged 50 with NIDDM and positive CVD family history on TFV/3TC.

20. Impact of the survey • When asked whether they were contemplating any change in their clinical practice as a result of completing the CVD management section of the questionnaire: • 64 (47%) of respondents said “Yes” • 45 (33%) said “No” • 28 (20%) were not sure or did not answer.

21. Conclusions of cardiovascular risk survey • CVD risk assessment and monitoring appear thorough, except perhaps family history, recreational drug history and HDL cholesterol. • Access to lipid specialists, smoking cessation services and exercise classes is poor. • Waist circumference is rarely monitored. Its significance is unclear in HIV. • Most respondents base intervention on overall CVD risk rather than specific lipid thresholds. A minority report high thresholds for intervention for fasting triglycerides.

22. Preliminary findings of mortality audit • 133 centres took part, of which 40 reported no recent deaths. • 89 of the remaining 93 centres submitted patient data, on 397 deaths. • 10 of these deaths occurred outside the study period, leaving 387 included in the main analyses. • Audit covered practice in reviewing deaths and lessons learnt, as well as circumstances of death - full results for presentation Autumn 2006.

23. Immediate cause of death

24. “Scenario” leading to death

25. Relationship between size of centre and mortality scenarios

26. Mortality audit conclusions • Late diagnosis remains a major factor in HIV-related deaths, and undiagnosed patients may present at a wide range of centres. • Causes not directly attributable to HIV, including liver disease, CVD and malignancies, also account for a substantial proportion of deaths. • Further data analysis is in progress. A more detailed report in the Autumn will examine lessons learnt from review of deaths and issues raised.

27. … and finally • Please remember to have a chat with Sally or Hilary about the BHIVA standards project, and fill in their questionnaire.