Patients with HIV infection:
- Carry a complex disease which can be a great mimic of other illness. However, advances such as early treatment with antiretroviral therapy (ART) and effective treatment of opportunistic infections have improved prognosis considerably in recent years.
- Have a disease which carries social stigma together with much misunderstanding about the disease and how it can be transmitted. However, the Government is committed to improving public understanding of the condition and reducing health inequalities in high-risk groups.
- Have particular health needs which require understanding, co-ordination of health services and professional education.
- Are likely to require levels of care and knowledge beyond the scope of unprepared general practices. However, a knowledge and an appreciation of the health needs involved are likely greatly to improve overall care of HIV-positive patients. There is a call for practices to become involved in the shared care of HIV-positive patients in much the same way as they are involved with the management of other chronic diseases.
In 2013, a total of 6,000 persons (4,500 men and 1,500 women) were newly diagnosed with HIV in the UK. The number of newly diagnosed heterosexual men and women has dropped over the years from 4,890 in 2004 to 2,490 in 2013 due to fewer diagnoses among people born in sub-Saharan Africa. 76% of infections in men who had sex with men (MSM) were acquired in the UK.19% of new diagnoses of HIV in 2012 were black Africans. Black Africans tend to present late in the infection, suggesting that more could be done to encourage early testing.Research in 2011 suggested that 48% of people born abroad are likely to have acquired infection in the UK.
107,800 people were estimated to be living with HIV in the UK in 2013. The overall prevalence was 2.8 per 1,000 population aged 15-59 years (1.9 per 1,000 women and 3.7 per 1,000 men). It was estimated that a quarter of people living with HIV were unaware of their infection.
Management of HIV-positive individuals in primary care
With the increased survival of patients treated with ART, the management of HIV in primary care has become much the same as for any other long-term condition. Shared care with local specialist clinics is becoming increasingly common. Guidelines for primary care teams have been produced by the Medical Foundation for AIDS and Sexual Health (MedFASH).
GPs and their teams should consider the following aspects of care:
It is important when dealing with medical aspects of sexual health and the presence of HIV infection that practitioners be sensitive to the emotive nature of all aspects of care. Newly diagnosed patients are likely to need much emotional support. Some may have been unaware of their risk until diagnosed (eg, during antenatal screening).
As with any other chronic disease, measures to maximise health are important. Issues may include:
- Cardiovascular disease prevention: for reasons unknown, patients with HIV are at increased risk. ART can increase the risk of diabetes and dyslipidaemia.
- Cervical screening: women with HIV are more prone to human papillomavirus-related diseases and should have annual screening smears.
- Immunisation (adults):
- Annual influenza.
- Hepatitis B testing and immunisation where appropriate.
- Hepatitis A immunisation for MSM.
- Pneumococcal vaccination.
- Swine flu vaccination.
- Immunisation (children): specialist advice should be sought for HIV-positive children and the children of HIV-positive parents.
Reproductive and sexual health
- Primary care teams should be supportive, uncritical and non-prejudiced. Safe sex advice should be provided at appropriate opportunities; this may include provision of condoms and lubricants or advice as to where these can be obtained according to local protocols.
- HIV-positive patients should be under regular review and have:
- Sexual health assessment at diagnosis and six-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).
- Patients should be made aware of post-exposure prophylaxis after sexual exposure (PEPSE). See 'Post-exposure prophylaxis (PEP)', below.
- Contraception: many antiretrovirals are enzyme-inducing. The effectiveness of combined and progestogen-only pills and hormonal patches can all be reduced so condoms should be used as well. Implants can be affected by some antiretrovirals but other long-acting reversible contraception (LARC) methods are not. Copper intrauterine contraceptive devices (cu-IUCDs) are the method of choice for emergency contraception but MedFASH also recommends the unlicensed use of double-dose Levonelle®. Specialist advice should be sought in cases of doubt.
- Fertility: specialist advice may be required if one partner is HIV-positive but conception is required.
- Antenatal care: specialists will no doubt be mainly involved but women may be anxious about transmission to the baby. Options to minimise the risk include ART during pregnancy, caesarean section and avoiding breast-feeding.
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. There is a need to have readily available information (eg, CD4 counts, ART) whilst at the same time ensuring that such data are only accessed on a need-to-know basis. MedFASH and the General Medical Council (GMC) have both produced guidance on this issue.[11, 14]
It is preferable that any clinician who treats the patient be 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.
- 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 workplace.
- 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 practise safe sex) the doctor may feel that he/she is in a difficult position.
- Discussion with a medical defence organisation may be appropriate.
- However, it is likely to be more helpful to speak to the genitourinary (GUM) 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; however, the GMC advises that GPs and other healthcare workers should be aware of the issues raised. 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).
- 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 is available on the Terrence Higgins Trust website.
- Public health (and the public interest).
- The doctor-patient relationship.
- Creating a trusting environment where such issues can be discussed.
- Duty of care:
Post-exposure prophylaxis (PEP)
PEP can be an important aspect of the care of HIV-positive patients. 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 separate article HIV Post-exposure Prophylaxis.
HIV infection and associated diseases
Protecting self and staff
- 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.
- Staff who handle clinical material should be immune from hepatitis B.
- In primary care the greatest risk is needlestick injury and needles should not be re-sheathed. There is some evidence that double gloving significantly reduces the amount of blood transferred during needlestick injury. Triple gloving and the use of gloves made of special materials are being investigated.The amount of blood necessary to transmit HIV is substantially more than to transmit hepatitis B or C. See separate Needlestick Injury article for more details.
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 them and be 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 MedFASH guidelines are particularly helpful.
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.
- 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.
See separate HIV Counselling article for further details.
Further reading and references
HIV in the United Kingdom: 2014 Report; Public Health England
Management of co-infection with HIV-1 and hepatitis B or C virus; British HIV Association (2010)
Guidelines for the treatment of TB/HIV coinfection; British HIV Association (2011)
Le Douce V, Janossy A, Hallay H, et al; Achieving a cure for HIV infection: do we have reasons to be optimistic? J Antimicrob Chemother. 2012 Feb 1.
Guidelines for the management of HIV infection in pregnant women (2014 interim review); British HIV Association
Ambrosioni J, Calmy A, Hirschel B; HIV treatment for prevention. J Int AIDS Soc. 2011 May 2514:28.
Concise guideline: Testing for HIV; Royal College of Physicians (2009)
Rutledge SE, Whyte J, Abell N, et al; Measuring stigma among health care and social service providers: The HIV/AIDS AIDS Patient Care STDS. 2011 Nov25(11):673-82. Epub 2011 Oct 3.
Standards for HIV clinical care; British HIV Association (2007)
PHE action plan 2015-16 Promoting the health and wellbeing of gay, bisexual and other men who have sex with men; Public Health England, 2015
Ford-Young W et al; HIV in Primary Care, British HIV Association, 2013
HIV: surveillance, data and management; Public Health England, 2015
Epidemiological status; UNAIDS, 2015
HIV in the United Kingdom: 2014 Report; Public Health England
HIV and AIDS in the UK; AVERT
HIV and Black African Communities in the UK; National Aids Trust, 2014
HIV in Primary Care; Medical Foundation for AIDS & Sexual Health (2011)
Guidelines for immunization of HIV-infected adults; British HIV Association (2008)
Guidelines for the management of sexual and reproductive health of people living with HIV infection; British HIV Association (2008)
Confidentiality: disclosing information about serious communicable diseases; General Medical Council, 2013
Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure; British Association for Sexual Health and HIV (2011)
HIV post-exposure prophylaxis; Guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS, Dept of Health, 2008
HIV-infected healthcare workers: guidance and management; Public Health England, January 2014
Mischke C, Verbeek JH, Saarto A, et al; Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel. Cochrane Database Syst Rev. 2014 Mar 73:CD009573. doi: 10.1002/14651858.CD009573.pub2.
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