The DocsThe DocsHIV care –A GP perspectiveHIV care –A GP perspective

The DocsThe Docs

City centre ManchesterCity centre Manchester

6500 patients6500 patients

3 GP partners, 2 practice nurses,1 HIV 3 GP partners, 2 practice nurses,1 HIV specialist nurse, 1 CBT therapist specialist nurse, 1 CBT therapist (1day/wk)(1day/wk)

217 patients with HIV (200 pts 217 patients with HIV (200 pts asthma/hypertension 100 diabetics!)asthma/hypertension 100 diabetics!)

Almost all HIV patients=MSMAlmost all HIV patients=MSM

HIV Intelligence system, Liverpool John Moores University, 2009.

Route of infection and ethnicity of HIV positive attendees at the Docs, 2009

Infection Route Ethnicity

HIV Intelligence system, Liverpool John Moores University, 2006 - 2009.

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

Specialist HIV nurse/Lead GPSpecialist HIV nurse/Lead GP

HIV Screening at The DocsHIV Screening at The Docs

Same day tests every WednesdaySame day tests every Wednesday

177 HIV tests performed Jan-Nov 2010177 HIV tests performed Jan-Nov 2010

6 tests = HIV positive6 tests = HIV positive

Full STI screens offeredFull STI screens offered

On site treatment chlamydia/GCOn site treatment chlamydia/GC

Immunisation Hep A/B to at risk groupsImmunisation Hep A/B to at risk groups

New Diagnosis of HIVNew Diagnosis of HIVnurse lednurse led

HIV test repeatedHIV test repeated

Full STI screen inc HepatitisFull STI screen inc Hepatitis

LFTs/U+E’s/cryptococcal LFTs/U+E’s/cryptococcal Ag/toxoplasma/CMVAg/toxoplasma/CMV

CD4/viral loadCD4/viral load

New DiagnosisNew DiagnosisWhat happens next?What happens next?

Patient seen by SWJ in 1/52 to discuss Patient seen by SWJ in 1/52 to discuss resultsresultsBHIVA guidelines + patient choiceBHIVA guidelines + patient choiceIf patient well/results good (CD4>350) If patient well/results good (CD4>350) repeat in 1/12repeat in 1/12Ongoing discussion about when/which Ongoing discussion about when/which hospital patient wishes to be referred tohospital patient wishes to be referred toDecision to refer-patient choice+/- falling Decision to refer-patient choice+/- falling CD4/rising viral loadCD4/rising viral load

BHIVA recommendations for BHIVA recommendations for starting therapystarting therapy

Primary HIV infectionTreatment in clinical trialor neurological involvementor CD4 <200 cells/mL >3/12or AIDS-defining illnessEstablished HIV infectionCD4 <200 cells/mL TreatCD4 201–350 cells/mL Treat as soon as possible when patient readyCD4 351–500 cells/mL Treat in specific situations with higher risk ofclinical eventsCD4 >500 cells/mL Consider enrolment into ‘when tostart’ trialAIDS diagnosis Treat (except for tuberculosiswhen CD4 >350 cells/mL

Ongoing monitoring of patients with Ongoing monitoring of patients with HIVHIV

CD4/viral load bloodsCD4/viral load bloods

Lipids/LFTs/U+E/glucose/OGTTLipids/LFTs/U+E/glucose/OGTT

BP checksBP checks

Convenient for patients to attend surgery Convenient for patients to attend surgery before work for bloodsbefore work for bloods

SWJ faxes results to hospital before SWJ faxes results to hospital before appointmentappointment

Primary care servicesPrimary care servicesnurse nurse

Smoking cessationSmoking cessationCVD risk calculation using QRISKCVD risk calculation using QRISKRenal function using ACR/eGFRRenal function using ACR/eGFRSTI screenSTI screenSmearsSmearsAnnual Flu jabAnnual Flu jabH1N1H1N15 yearly pneumococcal vaccine5 yearly pneumococcal vaccineCBT trained nurse practitionerCBT trained nurse practitioner

Primary care services Primary care services GPGP

Diagnosis and treatment of other illnesses Diagnosis and treatment of other illnesses (HAART drugs on computer system-warns (HAART drugs on computer system-warns of interactions)of interactions)

Rationalising non HAART medsRationalising non HAART meds

Reduction programme benzo/z drugsReduction programme benzo/z drugs

Chronic disease management Chronic disease management (renal/bone/lipid/hypertension)(renal/bone/lipid/hypertension)

Diagnosis/mx mental health problemsDiagnosis/mx mental health problems

HIV workload at The DocsHIV workload at The Docs

2010 177 HIV tests performed -6 positive 2010 177 HIV tests performed -6 positive

July-Dec 2010 July-Dec 2010 599599 appointments in appointments in surgerysurgery

Sexual health screening and treatmentSexual health screening and treatment

Increasing incidence of Anal Ca, Increasing incidence of Anal Ca, osteoporosis, IHD, palliative care issuesosteoporosis, IHD, palliative care issues

Ageing population-developing Ageing population-developing HT,Diabetes, COPDHT,Diabetes, COPD

HIV-New DiagnosisHIV-New DiagnosisPA dob 1972PA dob 1972

21/12/09 BA –unwell 3/52. 5day h/o red 21/12/09 BA –unwell 3/52. 5day h/o red rash, slightly itchy on trunk/limbs.rash, slightly itchy on trunk/limbs.

MSM, always uses condoms. Nurse.MSM, always uses condoms. Nurse.

Adv to have same day testAdv to have same day test

Sick note 1/52Sick note 1/52

HIV New DiagnosisHIV New DiagnosisPAPA

23/12/09 HIV and p24 positive23/12/09 HIV and p24 positive

Results discussedResults discussed

Sick note 2/52Sick note 2/52

5/1/10 CD4 329 5/1/10 CD4 329

Viral load 310578Viral load 310578

13/1/10. s/b BA. Long chat. Arr occ health. 13/1/10. s/b BA. Long chat. Arr occ health. Sick note 11/1/10-1/2/10Sick note 11/1/10-1/2/10

HIV New DiagnosisHIV New DiagnosisPAPA

3/2/10 staged return to work –feeling ok3/2/10 staged return to work –feeling okCD4 499CD4 499Viral load 238998Viral load 23899817/2/10 s/b BA back at work full time. 17/2/10 s/b BA back at work full time. Tired.Tired.31/3/10 flu/pneumococcal31/3/10 flu/pneumococcalHep A immune/syph negHep A immune/syph negViral load 179324Viral load 179324

HIV New DiagnosisHIV New DiagnosisPAPA

12/5/10 CD4 390, viral load 13830212/5/10 CD4 390, viral load 138302

9/6/10 not feeling good CD4 319/viral load 9/6/10 not feeling good CD4 319/viral load 147526147526

11/6/10 –pt would like referral to 11/6/10 –pt would like referral to Withington GUWithington GU

26/7/10 seen in clinic. Truvada/Etravine 26/7/10 seen in clinic. Truvada/Etravine startedstarted

Long Term Care HIV+ve Long Term Care HIV+ve BN dob 1959 HIV+ve 1998BN dob 1959 HIV+ve 1998

Sep 03 ulcerative gingivitis –adv bloodsSep 03 ulcerative gingivitis –adv bloods

Mar 04 candidal oesophagitis –adv bloodsMar 04 candidal oesophagitis –adv bloods

Apr CD4 328 –adv attend hospApr CD4 328 –adv attend hosp

July took HAART for 3 days -sfxJuly took HAART for 3 days -sfx

Sep candidiasis mouth, CD4 200Sep candidiasis mouth, CD4 200

Oct abdo pain/diarrhoea GP arr admitOct abdo pain/diarrhoea GP arr admit

didn’t go in!didn’t go in!

Sharing care BNSharing care BN

2005 attended 21 appts-oral thrush/D+V2005 attended 21 appts-oral thrush/D+V

2006 attended 8 appts –chest infections2006 attended 8 appts –chest infections

2007 attended 4 appts –chest infections2007 attended 4 appts –chest infections

Taking HAART-good response Taking HAART-good response

Tenofovir/FTC/atazanavir/RitonavirTenofovir/FTC/atazanavir/Ritonavir

Sharing care BNSharing care BN

Feb 08 - MAU subacute encephalopathyFeb 08 - MAU subacute encephalopathyExtensive Ix -HIV encephalopathyExtensive Ix -HIV encephalopathyNursing home June 2008Nursing home June 2008Woke up! all possessions goneWoke up! all possessions goneSep 08 –back to work at casinoSep 08 –back to work at casinoNov 08 –bus pass/DLANov 08 –bus pass/DLAApr 09 – smoking cessation Apr 09 – smoking cessation (pneumothorax)+COPD(pneumothorax)+COPD

Sharing care BNSharing care BN

Aug 09 Casino medical-unfit for dutiesAug 09 Casino medical-unfit for duties

Sep Non attendance at hospSep Non attendance at hosp

Nov move care to HopeNov move care to Hope

Mar 10 move back to MRI Mar 10 move back to MRI

Apr Incapacity benefit stopped.Apr Incapacity benefit stopped.

May Supporting letters = decision upheldMay Supporting letters = decision upheld

Sep benefits reinstated on appeal.Sep benefits reinstated on appeal.

Oct pincer movt –agrees to restart HAARTOct pincer movt –agrees to restart HAART

Sharing CareSharing CareBNBN

6/1/11 infective exacerbation COPD6/1/11 infective exacerbation COPDAdmitted MRI –discharged same dayAdmitted MRI –discharged same day20/1/11 continued deterioration COPD20/1/11 continued deterioration COPDStops HAARTStops HAARTSW/Nursing packageSW/Nursing package14/2/11 999 A+E-discharged same day, 14/2/11 999 A+E-discharged same day, phonecalls from neighboursphonecalls from neighboursPalliative care listPalliative care list15/2/11 misses Hospital appt (transport fails to 15/2/11 misses Hospital appt (transport fails to arrive)arrive)

Shared Care BNShared Care BN

2011 -10 encounters –visits/phonecalls, 2011 -10 encounters –visits/phonecalls, involving all 3 GPs and specialist nurseinvolving all 3 GPs and specialist nurse

Coordination of nursing/SW/hospitalCoordination of nursing/SW/hospital

Palliative care BUT rapid deterioration –Palliative care BUT rapid deterioration –emailing GU consultant to get assessmentemailing GU consultant to get assessment

18/2/11 –improvement with antibiotics, 18/2/11 –improvement with antibiotics, less SOBless SOB

IssuesIssues

Non attendanceNon attendance

Co-morbidities –COPDCo-morbidities –COPD

Compliance with HAARTCompliance with HAART

Social implications-work/benefits/DLASocial implications-work/benefits/DLA

Rapid deterioration –not due to HIV? Rapid deterioration –not due to HIV? Difficult to get medics interestedDifficult to get medics interested

General issues for discussionGeneral issues for discussion

Importance of communication between Importance of communication between primary/secondary careprimary/secondary care

HAART interactions –a minefield for GPs HAART interactions –a minefield for GPs unaware of HIV status/medicinesunaware of HIV status/medicines

Chronic disease mxChronic disease mx

Increasing age of people with HIV –in next Increasing age of people with HIV –in next 5yrs 50%>50yrs 5yrs 50%>50yrs

The DocsThe DocsDr Barbara AllanDr Barbara Allan

GP partner/trainerGP partner/trainer55-59 Bloom Street M1 3LY55-59 Bloom Street M1 3LY

Barbara.allan@nhs.net