Dr Anna Pryce GUM SpR, Royal Hallamshire Hospital February 2011

1. Positively Together Patient pathways Dr Anna Pryce GUM SpR, Royal Hallamshire Hospital February 2011

2. Patient Pathways: Outline • HIV in Sheffield • Testing pathways • Local innovation • Care pathways • Discussion

3. HIV in Sheffield • 1 in 700 people in Sheffield have been diagnosed with HIV • Around 750 people receive care in Sheffield (including non-residents) • People of African origin and men who have sex with men are disproportionately affected • 47 % are diagnosed late (CD4<200)

4. Late diagnoses by PCT Yorkshire and the Humber

5. Guidance on testing: • HIV in the United Kingdom: 2009 Report (HPA): • “Initiatives to expand HIV testing in clinical and community settings should be promoted” • 2008 National Guidelines for HIV testing: • Tests should be offered to all adults registering in general practice and to all general medical admissions where HIV prevalence is >2/1000 (Sheffield 1.4/1000) • NICE guidelines: Increasing uptake of HIV testing amongst black Africans and MSM (due March 2011).

6. Opportunities for testing • Screen in high prevalence areas >2/1000 • Test if risk factors (may need episodic testing) • Test if symptoms of primary HIV infection/seroconversion illness • Test if indicator diseases

7. De-mystifying HIV testing • All healthcare professionals should be able to obtain informed consent • Lengthy pre-test counselling un-necessary • Testing should be normalised • All those offering testing should be aware of referral pathways to specialist services

8. Testing for HIV • HIV test • may be positive from 2.5 weeks • repeat test at 3/12 still recommended • Send serum sample with virology form specifying “HIV test” • Organise follow-up with patient in 1 week • Support is available for all REACTIVE results

11. Local innovation • HIV sampling for MSM in Sheffield • Salivary sampling pilot 2009 • 126 kits distributed (60 returned) • 38% never tested before • 28% bisexual • No HIV diagnoses

12. Other local innovations • Gilead UK and Ireland Fellowship funded outreach testing in Black African communities • Partner testing study • Routine testing in General Practice • Targeted HIV testing in ITU The routine offer and recommendation of HIV testing in primary care and hospital settings is feasible and acceptable to patients and staff.

13. Shared care pathways • Intra hospital care pathways • e.g. Karposi sarcoma, antenatal, renal, hepatitis co-infection etc. • Joint care pathways with General Practice • Not yet established • Great scope for joint expertise in long term clinical management e.g. hyperlipidaemia, hypertension, eczema, asthma/COPD etc. • Cytology and vaccinations • Partnerships with other care providers • IVDU, alcohol, asylum seekers • Partnerships with voluntary organisations

14. HIV care pathways • Use CD4 count to decide if health problem likely to be related to HIV • If poor CD4 count discuss with HIV specialist • Encourage communication between GP and HIV specialist • Important both ways – we want to know about non-HIV health problems!

15. Further information • http://www.medfash.org.uk/publications/documents/HIV_in_Primary_Care.pdf • http://www.bashh.org (National Guidelines for HIV testing) • http://www.bhiva.org/TreatmentofHIV1_2008.aspx (HIV Treatment Guidelines) • http://guidance.nice.org.uk/PHG/Wave19/3 (Draft NICE Guidelines for black Africans) • http://guidance.nice.org.uk/PHG/Wave19/4 (Draft NICE Guidelines for MSM)

16. Discussion • Barriers to HIV testing and accessing care • Communication between HIV specialists and other care providers • Development of shared care pathways Contact details: anna.pryce@sth.nhs.uk