HIV in primary care. How effective and safe are HIV testing and care in General Practice?

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1 HIV in primary care How effective and safe are HIV testing and care in General Practice? Dr Werner Leber GP and Clinical Lecturer in Primary Care and Public Health Queen Mary, University of London

2 Overview Introduction Why diagnosing HIV early? How effective and safe is HIV testing in General Practice? The RHIVA2 cluster randomised trial How safe is HIV care in General Practice? Service evaluation in Hackney general practices Implications on future research, and local and national health care policy.

3 Rapid HIV testing in Hackney general practice The RHIVA 2 pragmatic cluster randomised controlled trial Dr Werner Leber GP and clinical lecturer in primary care Centre for Primary Care and Public Health, QMUL

4 HIV in the UK the facts Treatable chronic medical condition More than 96,000 HIV patients in the UK (2011) 24% unaware they are infected 47% diagnosed late (CD4<350) Indication for initiation of treatment 23% diagnosed very late (CD4<200) One of the definitions of AIDS - Source: Health Protection Agency. HIV in the United Kingdom: Report Health Protection Agency. HIV in the United Kingdom: 2012 Report. Data are from the Survey of Prevalent HIV Infections Diagnosed (SOPHID) collected from patients attending HIV care in the UK and from unlinked anonymous surveys in pregnant patients, intravenous drug users and patients attending GUM clinics.

5 The dangers of late diagnosis (CD4<350) 5-fold higher chance of developing AIDS-associated illnesses (Mocroft, 2013) 10-fold higher chance of dying within the first year of diagnosis (HPA, 2012) Increased risk of unwitting onward transmission due to continuing risk behavior and high infectivity (Girardi et al, 2007) Enormous burden to the health care budget (HPA, 2011) For each case prevented, K saved in live time treatment costs Mocroft et al. COHERE Study. CID, Health Protection Agency. HIV in the United Kingdom: Report May et al. UK Collaborative HIV Cohort (UK CHIC) Study. BMJ, Girardi et al. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. Journal of AIDS, 2007.

6 Additional years expected to live Delayed treatment reduces life expectancy Life expectancy at age UK Population <100 CD4 count (cells/microl) Life expectancy is 15 years lower compared to those receiving timely treatment. May et al. UK Collaborative HIV Cohort (UK CHIC) Study. BMJ UK population: Yorkshire and Humber Public Health Observatory,

7 National recommendation: Routine opt-out HIV testing British HIV Association (BHIVA) Guidelines 2008: Routine opt-out HIV testing in areas of high prevalence (>2/1000 population): Hospital admissions New registrants in primary care Hackney: 8/1000 diagnosed Tower Hamlets: 5.8/1000

8 Can rapid HIV testing at first presentation in General Practice Detect HIV earlier? Diagnose more people living with HIV? - Successful TB screening trial (Griffiths et al., 2007) Griffiths C, Sturdy P, Brewin P, Bothamley G, Eldridge S, Martineau A, et al. Educational outreach to promote screening for tuberculosis in primary care: a cluster randomised controlled trial, Lancet, 2007.

9 All participating Hackney surgeries: Standard of care for HIV testing continues Support throughout the study Intervention: INSTI TM rapid HIV test at New Patient Health Check General Practice Education Sessions Specialist referral of confirmed INSTI cases Control: Information on BHIVA HIV testing guidelines

10 Rapid HIV testing using INSTI TM Finger prick test result available in one minute Sensitivity = 99.6%; Specificity = 99.3% Any reactive test result needs confirmatory serology Quality Assurance

11 Results Baseline characteristics Characteristics of new registrants Intervention Control Number of new registrants 44,971 38,464 Mean age (years) Male 45% 45% White Black African 49% 17% 57% 15%

12 Results: HIV testing and diagnoses HIV testing and diagnoses Intervention Control Rapid HIV tests offered 11,180 NA Rapid HIV tests received 4,978 (44.5%) NA Reactive tests confirmed positive* 11 NA Total number of new diagnoses Black African MSM Total number of patients defaulted care >12 months 32 (incl. 3 antenatal) 20 (59%) 5 (16%) 4 14 (incl. 4 antental) 8 (57%) Nil 2 *All patients were successfully transferred to secondary care.

13 Primary outcome: Increase in early diagnosis of HIV CD4 count (cells/microl) Intervention Control Mean 356 (SD 254) 270 (SD 257) Square rooted CD4* Coefficient P-value CI (95%) Intervention to 7.4 Intervention excl. Antenatal to 11.6 *Mixed effect models allowing for a random effect of practice and adjusted for randomisation stratification factors, including practice list size, male HIV testing rate and IMD score.

14 Secondary outcome: Increase in the rate of new HIV diagnosis New diagnoses Intervention Control Total Antenatal Rate of new diagnosis (per 1000 patients per year)* Coefficient P-value CI (95%) Intervention to 16.0 Intervention excl. Antenatal to 20.2 *Mixed effect models allowing for a random effect of practice and adjusted for randomisation stratification factors, including practice list size, male HIV testing rate and IMD score.

15 Summary We demonstrate that GP education and rapid HIV testing offered to new registrants in Hackney general practice increases early diagnosis and rate of HIV detection The intervention is safe and has helps patients re-enter specialist care. To reduce undiagnosed and late presentation of disease, we recommend large scale HIV testing be implemented in UK general practices in high prevalence areas.

16 Implications RHIVA program expanded to nearly all Hackney general practices in 2012 Hackney sexual health LES: HIV included in April 2013 Public Health England 3Cs & HIV programme (2013): RHIVA protocol included Integrated HIV care research program for Hackney, Tower Hamlets and Newham starting in January 2014 (NIHR funded).

17 Centre for Health Sciences, QMUL Chris Griffiths Heather McMullen Sally Kerry Nadine Marlin Stephen Bremner Claire Kambiz Boomla Keith Prescott Martin Sharp Jack Dunne Homerton University Hospital NHS Trust Jane Anderson Sarah Creighton Danna Millett Sifiso Mguni Damilola Awosika Funding: NHS City & Hackney, Department of Health and UKCRN City & Hackney NHS Jose Figueroa UCL Graham Hart The London School of Hygiene and Tropical Medicine Fern Terris-Prestholt Andreia Santos Public Health England Valerie Delpech Alison Brown Graeme Rooney GP staff and patients Contact us:

18 Is Primary care prescribing for patients with HIV safe? A review of practice in an inner London borough For more detail please see Rosie Wellesley s presentation at:

19 Methods Borough-wide retrospective case notes review commissioned by public health team Electronic notes searches to identify patients living with HIV A survey team member assisted local GP GP records were updated and results fed back to individual surgeries

20 Results 31/43 (72%) Hackney general practices agreed to take part in the case notes review. 698/1022 (68%) HIV clinic letter available 413/787 (52%) patients had antiretrovirals correctly recorded 39/787 (5%) co-prescription of drugs contra-indicated in antiretrovirals Intranasal or inhaled steroids other than beclomethasone with proteinase inhibitors PPI with Atazanavir or Rilpivirine Simvastatin with any antiretroviral Excellent resource (including mobile app):

21 Increasing opportunities for HIV diagnosis in primary care A borough wide evaluation of HIV testing and prediagnosis care in general practice For more detail please see Alice Whittle s presentation at:

22 Methods Same as prescribing audit plus: Adults with a diagnosis of HIV made after 01/10/2008 plus 2 years of clinical notes available prior to diagnosis Up to 5 patient records were reviewed by the GP to document problem titles of GP face-to face consultations.

23 Results: Clinical setting of HIV diagnosis (n =89 patients) Desai M, Field N, Crompton J, Ruf M. Information for action: a method to inform HIV shared care planning in primary care at the PCT level. Sex Transm Infect 2011;87:295.

24 Results: Missed opportunities for diagnosis CONSULTATIONS (n=716) o 89 patients attended 716 face-to-face consultations with a GP over 2 years (range 0-29, median 7). o 119/716 (17%) of these were for indicator conditions. PATIENTS (n=89) o 13 indicator conditions were identified in 55 (range 0-4) patients. o 55/89 (62%)* had at least one indicator condition. * Similar to Dorward et al, Opportunities for earlier diagnosis of HIV in general practice. STI, 2012

25 Results: Indicator conditions (IC) (n=119)

26 Results: Unexplained neutropenia or low platelets Added: Initially NOT actively looked for. In 11/27 surgeries blood dyscrasias were consistently recorded for each patient. In these 11 surgeries, 33 patients that met the inclusion criteria. 11/33 (33%) with either low platelets or low neutrophils in the 2 years prior to diagnosis.

27 Acknowledgements Rosie Wellesley, Alice Whittle, Chris Griffiths, Heather McMullen Centre for Primary Care and Public Health; Barts and The London School of Medicine and Dentistry Jack Dunne, Martin Sharp Clinical Effectiveness Group; Barts and The London School of Medicine and Dentistry Jane Anderson, Sarah Creighton, Danna Millet, R. Castles Homerton University Hospital NHS Foundation Trust Joyce Mahungu Barts and the London NHS Trust Jose Figueroa City and Hackney Teaching Primary Care Trust