The Docs HIV care –A GP perspective

1. The DocsHIV care –A GP perspective

2. The Docs • City centre Manchester • 6500 patients • 3 GP partners, 2 practice nurses,1 HIV specialist nurse, 1 CBT therapist (1day/wk) • 217 patients with HIV (200 pts asthma/hypertension 100 diabetics!) • Almost all HIV patients=MSM

3. Route of infection and ethnicity of HIV positive attendees at the Docs, 2009 Infection Route Ethnicity HIV Intelligence system, Liverpool John Moores University, 2009.

4. Access to services and shared care • 80% of the Docs’ patients travel less than two miles to access the Docs • Most patients were also seen in a hospital clinic, but 8% solely used the Docs in 2009 HIV Intelligence system, Liverpool John Moores University, 2006 - 2009.

5. Specialist HIV nurse/Lead GP

6. HIV Screening at The Docs • Same day tests every Wednesday • 177 HIV tests performed Jan-Nov 2010 • 6 tests = HIV positive • Full STI screens offered • On site treatment chlamydia/GC • Immunisation Hep A/B to at risk groups

7. New Diagnosis of HIVnurse led • HIV test repeated • Full STI screen inc Hepatitis • LFTs/U+E’s/cryptococcal Ag/toxoplasma/CMV • CD4/viral load

8. New DiagnosisWhat happens next? • Patient seen by SWJ in 1/52 to discuss results • BHIVA guidelines + patient choice • If patient well/results good (CD4>350) repeat in 1/12 • Ongoing discussion about when/which hospital patient wishes to be referred to • Decision to refer-patient choice+/- falling CD4/rising viral load

9. BHIVA recommendations for starting therapy • Primary HIV infection • Treatment in clinical trial • or neurological involvement • or CD4 <200 cells/mL >3/12 • or AIDS-defining illness • Established HIV infection • CD4 <200 cells/mL Treat • CD4 201–350 cells/mL Treat as soon as possible when patient ready • CD4 351–500 cells/mL Treat in specific situations with higher risk of • clinical events • CD4 >500 cells/mL Consider enrolment into ‘when to • start’ trial • AIDS diagnosis Treat (except for tuberculosis • when CD4 >350 cells/mL

10. Ongoing monitoring of patients with HIV • CD4/viral load bloods • Lipids/LFTs/U+E/glucose/OGTT • BP checks • Convenient for patients to attend surgery before work for bloods • SWJ faxes results to hospital before appointment

11. Primary care servicesnurse • Smoking cessation • CVD risk calculation using QRISK • Renal function using ACR/eGFR • STI screen • Smears • Annual Flu jab • H1N1 • 5 yearly pneumococcal vaccine • CBT trained nurse practitioner

12. Primary care services GP • Diagnosis and treatment of other illnesses (HAART drugs on computer system-warns of interactions) • Rationalising non HAART meds • Reduction programme benzo/z drugs • Chronic disease management (renal/bone/lipid/hypertension) • Diagnosis/mx mental health problems

13. HIV workload at The Docs • 2010 177 HIV tests performed -6 positive • July-Dec 2010 599 appointments in surgery • Sexual health screening and treatment • Increasing incidence of Anal Ca, osteoporosis, IHD, palliative care issues • Ageing population-developing HT,Diabetes, COPD

14. HIV-New DiagnosisPA dob 1972 • 21/12/09 BA –unwell 3/52. 5day h/o red rash, slightly itchy on trunk/limbs. • MSM, always uses condoms. Nurse. • Adv to have same day test • Sick note 1/52

15. HIV New DiagnosisPA • 23/12/09 HIV and p24 positive • Results discussed • Sick note 2/52 • 5/1/10 CD4 329 • Viral load 310578 • 13/1/10. s/b BA. Long chat. Arr occ health. Sick note 11/1/10-1/2/10

16. HIV New DiagnosisPA • 3/2/10 staged return to work –feeling ok • CD4 499 • Viral load 238998 • 17/2/10 s/b BA back at work full time. Tired. • 31/3/10 flu/pneumococcal • Hep A immune/syph neg • Viral load 179324

17. HIV New DiagnosisPA • 12/5/10 CD4 390, viral load 138302 • 9/6/10 not feeling good CD4 319/viral load 147526 • 11/6/10 –pt would like referral to Withington GU • 26/7/10 seen in clinic. Truvada/Etravine started

18. Long Term Care HIV+ve BN dob 1959 HIV+ve 1998 • Sep 03 ulcerative gingivitis –adv bloods • Mar 04 candidal oesophagitis –adv bloods • Apr CD4 328 –adv attend hosp • July took HAART for 3 days -sfx • Sep candidiasis mouth, CD4 200 • Oct abdo pain/diarrhoea GP arr admit • didn’t go in!

19. Sharing care BN • 2005 attended 21 appts-oral thrush/D+V • 2006 attended 8 appts –chest infections • 2007 attended 4 appts –chest infections • Taking HAART-good response • Tenofovir/FTC/atazanavir/Ritonavir

20. Sharing care BN • Feb 08 - MAU subacute encephalopathy • Extensive Ix -HIV encephalopathy • Nursing home June 2008 • Woke up! all possessions gone • Sep 08 –back to work at casino • Nov 08 –bus pass/DLA • Apr 09 – smoking cessation (pneumothorax)+COPD

21. Sharing care BN • Aug 09 Casino medical-unfit for duties • Sep Non attendance at hosp • Nov move care to Hope • Mar 10 move back to MRI • Apr Incapacity benefit stopped. • May Supporting letters = decision upheld • Sep benefits reinstated on appeal. • Oct pincer movt –agrees to restart HAART

22. Sharing CareBN • 6/1/11 infective exacerbation COPD • Admitted MRI –discharged same day • 20/1/11 continued deterioration COPD • Stops HAART • SW/Nursing package • 14/2/11 999 A+E-discharged same day, phonecalls from neighbours • Palliative care list • 15/2/11 misses Hospital appt (transport fails to arrive)

23. Shared Care BN • 2011 -10 encounters –visits/phonecalls, involving all 3 GPs and specialist nurse • Coordination of nursing/SW/hospital • Palliative care BUT rapid deterioration –emailing GU consultant to get assessment • 18/2/11 –improvement with antibiotics, less SOB

24. Issues • Non attendance • Co-morbidities –COPD • Compliance with HAART • Social implications-work/benefits/DLA • Rapid deterioration –not due to HIV? Difficult to get medics interested

25. General issues for discussion • Importance of communication between primary/secondary care • HAART interactions –a minefield for GPs unaware of HIV status/medicines • Chronic disease mx • Increasing age of people with HIV –in next 5yrs 50%>50yrs

26. The Docs Dr Barbara Allan GP partner/trainer 55-59 Bloom Street M1 3LY Barbara.allan@nhs.net