Mind the gaps David Baker East Sydney Doctors

1. Mind the gaps David BakerEast Sydney Doctors David Baker – East Sydney Doctors

2. Aims Gaps from a GP / S100 perspective • Prevention • Diagnosis • Treatment David Baker – East Sydney Doctors

3. HIV as a chronic infection At Risk Population Asymptomatic Symptom atic Acute illness Prevention Support Monitor Treatment David Baker – East Sydney Doctors

4. Epidemiology HIV infections Burnet study: 639 gay men in Melbourne 2008, oral salivary test, 61 +ve, 19 undiagnosed= 31% Diagnosed HIV +ve HIV diagnosed 70 – 80% = 20171 HIV in care ? NCHECR Annual surveillance report 2009 David Baker – East Sydney Doctors

5. Late diagnosis 17% classified as late diagnosis ie presented with CD4 < 200 in the period 2007 - 2009 NCHECR Annual surveillance report 2009 David Baker – East Sydney Doctors

6. Prevention in general practice Multiple interventions Counselling – safer sex PEP PREP Early treatment Frequent testing David Baker – East Sydney Doctors

7. Diagnosis in general practice Role in primary care High case load Low case load Currently low rate of testing ‘high risk’ MSM – only 20% tested twice a year Guy et al STI 2010 David Baker – East Sydney Doctors

8. GP diagnosed cases = 1731 NSW Health

9. GPs and HIV diagnosis • ~ 1/2 of the new HIV infections diagnosed each year are done by GPs • Of GP diagnosed patients about ½ are diagnosed by S100 GPs • About ¾ of GPs diagnosing HIV have diagnosed a single patient over the 8 year period NSW Health

10. Low case-load • 354 randomly selected Victorian GPs that showed poor HIV/STI knowledge and practices eg GPs generally underestimated the prevalence of HIV among MSM • sexual history taking from MSM was limited, with common barriers to sexual history taking  including limited time, inadequate training and discomfort/embarrassment on behalf of the GP • the thoroughness of the GP HIV risk assessment was often inadequate • routine and comprehensive HIV and other STI screening was limited and often only done when prompted by the patient. Barber B, et al., HIV and other sexually transmitted infections among men who have sex with men: knowledge and practices of general practitioners in Victoria., in Australasian Society or HIV Medicine (ASHM) Conference. 2009: Brisbane.

11. Barriers to testing Online PASH study reported that among those that had previously been tested barriers to testing were • returning for test results • convenience • not having an illness or symptoms • not having changed partners • fear of finding out they have HIV Prestage, G., et al., The PASH Study. 2009, NCHECR

12. Treatment Importance of adherence and persistence Lost to follow-up – about 5% per year form AHOD sites but outcomes unknown in this group Petoumenos 2010 David Baker – East Sydney Doctors

13. Current prognosis • Estimated survival of more than 35 years after diagnosis Lohse N  Survival of Persons with and without HIV Infection in Denmark 1995 –2005 Ann Int Med 2007, Jan 16 146: 87 – 95 David Baker – East Sydney Doctors

14. Mortality • AHOD – 1999 - 2004 • Mortality rate 1.58 people / year • 10 x age-matched • HIV related deaths: 40% • HIV unrelated deaths: 52% • lung cancer (13%) • suicide (11%) • AMI 9% • Unknown 8% Petoumenos et al , Sexual Health, 2006 David Baker – East Sydney Doctors

15. Under treated / poorly treated • Importance of co-morbidities • Winning the battle … losing the war

16. Challenges: Co-morbidity HIV + Hepatitis C 165 HIV 1480 Hepatitis C chronic 1476 David Baker – East Sydney Doctors

17. Challenges: malignancy David Baker – East Sydney Doctors

18. Challenges: cardiovascular David Baker – East Sydney Doctors

19. Challenges: aging and complexity 72 year old Medications: Diaformin 500 mg 1 bd Plendil ER 10 mg 1 bd Spiriva 18 mcg for inhalation 1 daily Questran Lite 4 g 1 bd Avapro HCT 300/12.5 1 daily Lipitor 80 mg 1 nocte Viramune 200 mg 1 bd Kivexa 1 bd Seretide Accuhaler (250/50) 1 bd Valtrex 500 mg 1 daily Sustanon 250 / 2 weeks Minipress 2 mg nocte Temaze 10 mg 1 nocte prn Nexium 40 mg 1 daily Aratac 200 mg 1 daily Warfarin 6 mg /d Rhinocort 64 mcg/dose 120 doses spray 1 bd Major diagnosis: Knee osteoarthritis Atrial fibrillation Gastro-oesophageal reflux disease with oesophagitis Migraine Hyperlipidaemia HIV infection Hypertension essential Chronic obstructive pulmonary disease Depression Prostatic hypertrophy Sleep apnoea Throat cancer 46 year old Medications: Avanza 30 mg 1 nocte OxyContin 35 mg bd Valtrex 500 mg 1 daily Stocrin 600 mg 1 daily Kivexa 1 daily Celebrex 200 mg 1 daily Zyloprim 100 mg 1 daily Panamax 500 mg 1-2 q4h prn Ventolin Inhaler 100 mcg/dose x 2 Inhaler 2 q4h prn Zoton 30 mg 1 daily Seretide Accuhaler (250/50 Inhalation 1 bd Major diagnosis: Liver function studies abnormal result Knee injury Genital herpes Pain chronic Alcohol excess Chronic obstructive pulmonary disease Lumbar spondylosis Cerebral aneury Depression HIV infection Gastro-oesophageal reflux disease Gout Hip arthritis 35 year old Medications: Kaletra 4 daily Truvada 1 daily Allegron 25 mg 2 nocte Stilnox7.5 mg 1 nocte prn Tramal 50 mg 1 bd prn Symbicort Turbuhaler 1 bd Coversyl 4 mg 1 daily Codeine Phosphate 30 mg 1 daily Nexium 20 mg bd Pregabalin 150 mg bd Panadol osteo 2 tds Major diagnosis: Smoker tobacco Gastro-oesophageal reflux disease with oesophagitis Neuropathy drug induced Neck injury HIV infection Hyperlipidaemia Hypertension Asthma Depression David Baker – East Sydney Doctors

20. Challenges: new epidemics Hep C David Baker – East Sydney Doctors

21. Challenges: side effects David Baker – East Sydney Doctors

22. Illness / health behaviour Treatment refusal Adherence Problems Treatment Interruption David Baker – East Sydney Doctors

23. Challenges: treatment problems Adherence Problems More Complex Treatment Treatment Interruption Resistance, Disease Progression David Baker – East Sydney Doctors

24. 15 years continuous treatment, no side effects No Treatment interruption David Baker – East Sydney Doctors

25. Started on HAART when developed KS at low CD4 then stopped, just restarted when KS returned at low CD4. patient has schizophrenia and depression ‘Bad’ Treatment Interruption KS KS David Baker – East Sydney Doctors

26. Poor adherence David Baker – East Sydney Doctors

27. Predicting Adherence Patient-Provider Disease Adherence Patient variables Socio-demographic Psychosocial Rx Setting Ickovic, JAIDS , 2002 David Baker – East Sydney Doctors

28. Demographics Not associated Ammassari, JAIDS, 2002 David Baker – East Sydney Doctors

29. Demographics Inconsistent predictor Ammassari, JAIDS, 2002 David Baker – East Sydney Doctors

30. Demographics Consistent predictor Ammassari, JAIDS, 2002 David Baker – East Sydney Doctors

31. HIV futures 6: use of ARVs

32. HIV futures 6: use of ARVs

33. HIV futures 6: Treatment Breaks • 38.1% of those currently on ARV had taken a break from ARV • The median length of break was four months • Doctors were less likely to be consulted before a break and during than afterward • 30.6% saw their doctor before, during and after the treatment break

34. Types of TI Structured treatment interruption (STI) = ‘supervised’, ‘scheduled’, ‘stupid’ (different authors) A purposeful treatment interruption Stopping treatment Monitored Unstructured treatment interruption Stopping medication “a drug holiday” Unmonitored Lost to follow-up Sanctioned Unsanctioned David Baker – East Sydney Doctors

35. Improved treatment • Reduce side effects – aim NO side effects • Simplify treatment • once a day dosing • no food restriction • no storage restrictions • increased ‘forgiveness’ of adherence errors David Baker – East Sydney Doctors

36. Improving adherence: reduce S/Es • Individualise medication to patients life style e.g. food intake • Switch to reduce side effects • Kaletra GI S/Es – try atavanavir • CNS S/Es switch efavirenz to nevirapine • Dose adjust • Use therapeutic drug monitoring • New better tolerated formulations David Baker – East Sydney Doctors

37. HIV futures 6

38. HIV futures 6

39. Specific interventions • DOT • phone reminders • adherence clinics • engage family, friends • pictures, pillboxes, calendars • peer counselors • team approach with nurses, pharmacists • simplify regimens, dosing • review and treat potential side effects, • education on medication dosing • establish readiness to start therapy David Baker – East Sydney Doctors

40. Treatment Lack of information about dynamics of treatment uptake, discontinuation rates and reasons Some evidence about what may be helpful Role of improved electronic systems in primary care eg reminders, SMS recalls David Baker – East Sydney Doctors

41. Summary – gaps Gaps in prevention – continuing new HIV +ve Gaps in testing / diagnosis – late diagnosis Gaps in treatment – higher mortality rates in HIV +ve, lost to follow-up, treatment interruptions, side effects / well-being David Baker – East Sydney Doctors

42. Summary – interventions Training and support for GPs high case load low case load Innovative approaches to increased testing eg computer reminder systems, walk-in clinics with rapid-testing Continuing active support of HIV +ve people with mental illness, drug/alcohol use and other co-morbidities, implementation of evidence-based adherence tools Increasing uptake of computerised systems eg electronic reminders, SMS to reduce lost to follow-up David Baker – East Sydney Doctors