Tuesday, March 17, 2009

Managing HIV Positive Individuals in Primary Care

Patients with HIV infection:

  • They carry a complex disease that can be a great mimic of other illness, that can progress and is incurable.
  • They have a disease that carries social stigma together with much misunderstanding about the disease and how it can be transmitted.
  • They have particular health needs which require understanding, coordination of health services and professional education.
  • They are likely to require levels of care and knowledge beyond the scope of unprepared general practices. However a knowledge and appreciation of the health needs involved is likely to greatly improve overall care of HIV-positive patients. Information for doctors and patients is readily available. For example the National Aids Trust website.1
Background

The incidence and prevalence of HIV infections continue to rise in the UK.2 HIV statistics in the UK are compiled by the Health Protection Agency.3 Internationally statistics are gathered by the United Nations Joint Programme on HIV and AIDS (UNAIDS).4

  • There were an estimated 53,000 adults infected with HIV living in the UK in 2003. The figure for 2005 was 63,500. Over 27% were not aware of their infection in 2001. About a third of HIV positive patients are estimated to be undiagnosed.1
  • Internationally there are over 40 million HIV positive people.1
  • In the UK a total of 6606 new HIV infections were diagnosed in 2003 rising to 7450 in 2005. Of these patients 57.5% acquired infection through heterosexual intercourse, two thirds were diagnosed in women and 70% were probably acquired in Africa.
  • In addition, 1477 HIV infections were diagnosed in children aged under 15 years of age at the end of 2003.

These figures and other statistics show:

  • It is a disease that affects ordinary people, including children and is not confined to particular populations.
  • It is not rare.
  • Cases are not evenly distributed throughout the country and there will be pockets of high incidence.
  • A quarter to one third of patients do not know that they are infected. Such individuals are not receiving treatment and may be spreading the disease.
  • It is necessary to be aware of risk. Recent arrivals from Africa and gay men are in a high risk group for example.1
  • There has been some recent complacency about the disease, treatment for the disease and risk of acquiring the disease. People are less aware of the risk of transmission of HIV than they were 10 years ago.1
  • There is an increasing number of HIV positive individuals living well, on suppressive antiretroviral treatment.
  • More attention is needed on the wider health needs of people living with HIV/AIDS (PLHA).2
Management of HIV positive individuals in primary care

There are a number of important aspects of the care of HIV positive patients which are particularly important in primary care. These are less to do with detailed technical knowledge (for example of antiretroviral drugs) and more to do with awareness of what the important aspects of care are likely to be and how, where and when further care should be accessed. It is necessary for healthcare staff (including receptionists) to have knowledge of HIV and of certain basic guidelines appropriate to their involvement in the care of HIV positive patients.

Emotional aspects of care

It is important when dealing with medical aspects of sexual health and the presence of HIV infection that practitioners are sensitive to the emotive nature of all aspects of care.2 This extends from an appreciation of the emotional aspects of discussing sexuality, sexual health and reproduction and should incorporate an awareness of even the terminology used when discussing care. Even unintentional use of judgemental or discriminatory language should be avoided. GPs should be aware of the need for extra care and what standards and specification of care should be provided, even though much of this may not take place in the GP setting.

Awareness of overall service provision

GPs should be aware of how services for HIV positive patients are organised locally.

Overall STI service specification for PLHA
Recent guidance sets high standards for care of PLHA.2 Such care may not always be adequately provided in Genitourinary medicine clinics. Service delivery should include:

  • Sexual health assessment at presentation and at six monthly intervals.
  • Provision of key preventive activities (including Hepatitis A, B and C screening and immunisation for A and B)
  • Access to investigation, diagnosis and treatment of STIs and partner notification
  • Syphilis serology at first diagnosis and three monthly thereafter
  • Annual cervical cytology in all HIV positive women (with prompt access to colposcopy when required)
  • Counselling to sero-discordant couples and availability of post-sexual exposure prophylaxis (PEP)
  • Information and advice on re-infection and superinfection
  • Access to contraceptive services (including provision of condoms)
  • Support around disclosure
  • Clear pathways for conception, pregnancy and fertility services

Confidentiality

Confidentiality is as important for HIV patients as it is for all other patients. HIV status is a particularly sensitive piece of information and patients will have additional concerns about confidentiality. It is worth discussing this with the patient and the practice to agree a policy. It is preferable that any clinician who treats the patient is aware of the diagnosis. These considerations have implications for:

  • Medical records:
    • It is important to consider how and where to record the diagnosis in the patient's computer record.
    • There may be implications for the NHS Care Record and Connecting for Health.
    • Needless to say written or Lloyd George records should not have a sticker saying HIV or AIDS on the front of the envelope!
  • Staff confidentiality:
    • Doctors should set an example by maintaining confidentiality and an appropriate attitude towards affected patients.
    • Doctors and nurses should know but receptionists do not have to.
    • Reception staff may get to know.
    • Education of staff about confidentiality and HIV may be appropriate.
  • Advice to the patient:
    • Share information or policies on confidentiality within the practice.
    • Discuss record keeping and sharing of information with outside agencies.
    • Encourage appropriate sharing of information with dental and other professional colleagues.
    • Discuss any implications for their work place.
    • Discuss advising sexual partners (sexual partners should be aware of the diagnosis).
  • Partner notification and disclosure:
    • If a patient declares unwillingness to inform a sexual partner of the diagnosis (or to practice safe sex) the doctor may feel that he/she is in a difficult position.
    • Discussion with medical defence organisation may be appropriate.
    • However it is likely to be more helpful to speak to the GU clinic responsible for HIV services to review approaches to management of this issue. Such discussions can of course maintain patient confidentiality. Such centres are encouraged to develop local policies and guidance on partner notification and disclosure.
    • No simple guidance on partner notification and disclosure can be issued but GPs and other health care workers should be aware of the issues raised.2 The subject raises issues of:
      • Duty of care:
        • To the patient (to diagnose, treat, advise)
        • To the patient's sexual partner(s)(as above and to protect from infection)
      • Confidentiality:
        • GP (or healthcare worker) has a legal responsibility to maintain confidentiality (unless consent to disclose is given)
        • GP (or healthcare worker) may disclose information on patients (living or dead) in order to protect another person from serious harm or death
        • Maintaining trust, avoiding legal threats and encouraging disclosure usually give more beneficial outcomes
        • Helpful information on this available Terrence Higgins Trust website5
      • Public health (and the public interest)
      • The doctor patient relationship
      • Creating a trusting environment where such issues can be discussed

Sexual health support

HIV-positive patients should be under regular review and have:2

  • Sexual health assessment at diagnosis and 6 monthly
  • Access to staff trained to carry out such sexual history and sexual health assessment
  • Access to high quality counselling and support to ensure good sexual health and to maintain protective behaviours
  • Offer of full annual sexual health screen (regardless of reported history)
  • Documented local care pathways for diagnosis, treatment and partner work for sexually transmitted infections (which are actively communicated to all members of clinic staff)

Post exposure prophylaxis6

Post exposure prophylaxis (PEP) can be an important aspect of the care of HIV-positive patients.2 A knowledge of the guidelines and procedures is very important and GPs should familiarise themselves with these guidelines and access to PEP. Details of this are covered in the article on PEP for HIV.

HIV infection and associated diseases

Important aspects of management of HIV infection in primary care are:

  • Progression of the disease:
    • Despite the great advances in antiretroviral therapy and the input from specialist care, primary care is often where advice is first sought on many aspects of HIV infection from diagnosis to other aspects of management.
    • GPs must be aware of the signs of progression of the disease and complications.

    AIDS defining conditions in adults
    Candidiasis of bronchi, trachea or lungsLymphoma, Burkitt's (or equivalent term)
    Candidiasis, oesophagealLymphoma, immunoblastic (or equivalent term)
    Cervical carcinoma, invasiveLymphoma, primary, of brain
    Coccidioidomycosis, disseminated or extrapulmonaryMycobacterium avium complex or M. kansasii, disseminated or
    extrapulmonary
    Cryptococcosis, extrapulmonaryMycobacterium tuberculosis, any site (pulmonary or
    extrapulmonary)
    Cryptosporidiosis, chronic intestinal (>1 month's duration)Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
    Cytomegalovirus disease (other than liver, spleen or nodes)Pneumocystis carinii pneumonia
    Cytomegalovirus retinitis (with loss of vision)Pneumonia, recurrent
    Encephalopathy, HIV-relatedProgressive multifocal leucoencephalopathy
    Herpes simplex: chronic ulcer(s) (>1 month's duration); or bronchitis, pneumonitis or oesophagitisSalmonella septicemia, recurrent
    Histoplasmosis, disseminated or extrapulmonaryToxoplasmosis of brain
    Isosporiasis, chronic intestinal (>1 month's duration)Wasting syndrome due to HIV
    Kaposi's sarcoma 

  • Complications of HIV infection are described elsewhere.
  • Progression to full blown AIDS is associated with a deteriorating clinical picture with more infection, especially of an opportunist nature and despite highly active anti-retroviral therapy (HAART) the risk of death from malignancy is high. It is not just the malignancies already mentioned that are common. Many other malignancies are associated with the condition.
  • The stages of disease and the significance of CD4 counts should be understood. The disease is divided into 3 stages according to CD4 count9:
    • Stage I: > 500 cells/mm3 (or CD4% > 28%)
    • Stage II: 200-499 cells/mm3 (or CD4% 14% - 28%)
    • Stage III: < style="color: rgb(0, 0, 0); font-weight: 400; vertical-align: super; font-size: 0.75em; ">3 (or CD4% <>
  • Co-infection:
    • The diagnosis of HIV is so catastrophic that it is easy to overlook the fact that there may be other diseases present too. If the disease was sexually acquired other sexually transmitted diseases can be present.
    • Referral to a GUM clinic (or the centre responsible for HIV services) may be advised for screening and contact tracing. If the disease resulted from drug abuse it is prudent to check for various types of hepatitis, especially hepatitis B and hepatitis C.
    • Another disease whose resurgence is in part related to HIV is tuberculosis and this is most likely in those who have come from Africa.
  • Immunisation:
    • HIV infection makes the individual susceptible to infections. It may be appropriate to undertake a course of immunisations to give as much protection as possible.The problem is that whilst the lack of immune competence predisposes to the disease, it also reduces the efficacy of response to the vaccine.
    • In childhood AIDS in Africa immunisation has shown a disappointing response.
    • The qualitative response to pneumococcal vaccine is poorer in HIV-infected children with lower functional antibody responses.10
    • Diphtheria, tetanus, pertussis vaccination can produce a specific response but the durability of the response is questioned.11
    • The response to Hib immunisation is poor.12
    • Cytomegalovirus is only a problem in the immunocompromised but development of a vaccine has been fraught with difficulties.13
    • In sub-Saharan Africa, control of measles by immunisation has been successful despite a very high incidence of HIV but that seems to be because those who fail to seroconvert have a very high mortality.14
    • Immunisation should be given early in the disease and before it progresses so as to get the best results. Some vaccines may cause a transient increase in the viral replication and HIV load.
    • Live vaccines must be used with great caution.15

Protecting self and staff

The risk of transmission in general practice is small. There are useful publications on this.16

  • The practice may still be involved in invasive procedures like taking of blood and biopsy of skin lesions, especially as dermatological malignancies are more common in this condition. Anyone performing such procedures must be aware of the patient's status. Nowadays gloves are worn for all invasive procedures in all patients. Some people use double gloves in the presence of HIV and there is much in the literature about this in various types of surgery.
  • In primary care the greatest risk is needle-stick injury and needles should not be re-sheathed. Double gloves impair dexterity and offer protection against body fluids but not against needle stickinjuries.17 The amount of blood necessary to transmit HIV is substantially more than to transmit Hepatitis B or C.
  • If an accident does occur post exposure prophylaxis (PEP) is indicated. This should start as soon as possible and certainly within 24 to 48 hours. Treatment is needed for just a month because the aim is to prevent HIV from entering cells in the body. Infection will either become established or curtailed within that period. Recent guidance from the Department of Health suggests PEP should be offered to healthcare workers exposed through needle stick injuries within one hour of exposure for maximum effectiveness. A study showed that treatment with AZT 24 hours after exposure reduced the risk of infection by 80%.18 If the patient has had antiretroviral therapy it may be wise to change the regime in case the virus has acquired resistance. Specialist help should be sought. The US Public Health Service also publish guidelines.19

Knowledge and education

Currently and historically ignorance has led to prejudices, discrimination and ultimately great distress to HIV-infected individuals. The GP of an infected patient should be well informed enough to help his patient and enlightened enough to challenge any prejudices or misconceptions about HIV particularly from patients, staff and colleagues. There is a wealth of information and several sites are listed for further reading and reference. The publication on HIV in Primary Care from the Medical Foundation for AIDS and Sexual Health is especially useful for GPs.20

Screening and counselling

Positive results may arise from HIV screening in a number of different circumstances. Some examples are given below. Any screening or testing requires appropriate counselling, informed consent and support. HIV counselling includes what the patient should be told before testing and after testing, whether the result is positive or negative.The GP may be involved in this and should be aware of the implications, procedures and management of patients faced with a positive HIV result.

  • Blood donors are screened for HIV.
  • All pregnant women are offered HIV testing. Antenatal testing has been prompted by the availability of interventions to reduce infant infection. This has been successful particularly in areas of high prevalence like London. Interventions to achieve this include:21
    • Antiretroviral treatment to prevent mother to child transmission22
    • Caesarean section23
    • Avoidance of breast feeding
    In the UK the majority of women will test negative but for some this will be the moment they discover their positive status. The testing process can involve counselling and education to prevent HIV infection. A positive result will have implications for patient, partner, any siblings, and the management of the pregnancy.
  • The patient may present and ask to be screened because of lifestyle or the knowledge or suspicion of an infected partner.
  • Testing may be indicated because certain diseases raise clinical suspicion. This may be conditions like shingles affecting multiple dermatomes, multiple infections or infections with atypical organisms. There are certain dermatological conditions that suggest the diagnosis.

Document references
  1. National AIDS Trust; Campaigning and Information
  2. Guidelines for the treatment of HIV-infected adults with antiretroviral therapy, The British HIV Association (2006)
  3. HPA; HIV and Sexually Transmitted Infections. Health Protection Agency
  4. UNAIDS; 2004 Report on the global AIDS epidemic, Bangkok conference.; Proceedings of this international meeting.
  5. Terrence Higgins Trust; Resources, help and information
  6. Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure, British Association for Sexual Health & HIV (2006)
  7. Cheung MC, Pantanowitz L, Dezube BJ; AIDS-related malignancies: emerging challenges in the era of highly active antiretroviral therapy. Oncologist. 2005 Jun-Jul;10(6):412-26. [abstract]
  8. Wilkins K, Dolev JC, Turner R, et al; Approach to the treatment of cutaneous malignancy in HIV-infected patients. Dermatol Ther. 2005 Jan-Feb;18(1):77-86. [abstract]
  9. Centers for Disease Control and Prevention; 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults.
  10. Madhi SA, Kuwanda L, Cutland C, et al; Quantitative and qualitative antibody response to pneumococcal conjugate vaccine among African human immunodeficiency virus-infected and uninfected children. Pediatr Infect Dis J. 2005 May;24(5):410-6. [abstract]
  11. Rosenblatt HM, Song LY, Nachman SA, et al; Tetanus immunity after diphtheria, tetanus toxoids, and acellular pertussis vaccination in children with clinically stable HIV infection. J Allergy Clin Immunol. 2005 Sep;116(3):698-703. [abstract]
  12. Madhi SA, Kuwanda L, Saarinen L, et al; Immunogenicity and effectiveness of Haemophilus influenzae type b conjugate vaccine in HIV infected and uninfected African children. Vaccine. 2005 Dec 1;23(48-49):5517-25. Epub 2005 Aug 1. [abstract]
  13. Schleiss MR, Heineman TC; Progress toward an elusive goal: current status of cytomegalovirus vaccines. Expert Rev Vaccines. 2005 Jun;4(3):381-406. [abstract]
  14. Helfand RF, Moss WJ, Harpaz R, et al; Evaluating the impact of the HIV pandemic on measles control and elimination. Bull World Health Organ. 2005 May;83(5):329-37. Epub 2005 Jun 24. [abstract]
  15. Pancharoen C, Ananworanich J, Thisyakorn U; Immunization for persons infected with human immunodeficiency virus. Curr HIV Res. 2004 Oct;2(4):293-9. [abstract]
  16. HIV Infected Health Care Workers: Guidance on Management and Patient Notification, Department of Health (2005)
  17. Mansour AM; Needlestick injury in the OR: facts and prevention. J Ophthalmic Nurs Technol. 1989 Nov-Dec;8(6):222-4. [abstract]
  18. Cardo DM, Culver DH, Ciesielski CA, et al; A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997 Nov 20;337(21):1485-90. [abstract]
  19. Panlilio AL, Cardo DM, Grohskopf LA, et al; Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005 Sep 30;54(RR-9):1-17. [abstract]
  20. HIV in Primary Care, Medical Foundation for AIDS & Sexual Health (2005)
  21. Brocklehurst P; Interventions for reducing the risk of mother-to-child transmission of HIV infection.;Cochrane Database Syst Rev. 2002;(1):CD000102. [abstract]
  22. Brocklehurst P, Volmink J; Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev. 2002;(2):CD003510. [abstract]
  23. Read JS, Newell MK; Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005479. [abstract]
Internet and further reading
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