Hiv in the General Practice Setting

Joe Murtagh
It’s easy to get confused....
What we will cover today
 HIV overview
 HIV testing
 HIV therapy (the bare bones!)
 Post exposure prophylaxis (PEP)
 Case scenarios
 Top tips for you and summing up
Why do you need to know?
What’s changed in last decade?
 Early diagnosis – expanded screening
 Reduced mother to child transmission
 More education
 More sensible publicity
 ? More complacency
Benefits of knowing HIV status
 Access appropriate care
 Reduction in morbidity and mortality
 Reduction in vertical transmission
 Reduction in sexual transmission
 Infection control
 Cost effectiveness
Why do GP’s not test for HIV?
 Underestimate the risk/ rates in their patient
 Misconceptions about time restraints for detailed pretest counselling
 Anxiety about false positives
 Concerns about ‘opening a can of worms’
 Unsure how to follow this up
GPs’ perceived barriers to their involvement in caring for
patients with HIV British Journal of General Practice. Defty et al. May 2010
 n=124 (90% had held HIV / Gum post)
 23% felt unable to distinguish between HIV related
conditions and other illnesses
60% felt GPs should be managing problems such as
hypertension, hyperlipidaemia and diabetes
Prescribing (79% difficulty keeping up to date with current
anti-HIV therapies, 72% knowledge of side effects, 46%
drug interaction)
67% believed their patients wanted HIV to be managed by
specialist (20% believed their patients thought all health
issues should be managed by HIV specialist)
Strong significance in labelling time and interest as a
barrier to taking on more HIV related care in the future
What tests available?
 Serum antibodies detect > 99% at 3/12
 4th generation IgM and p24 antigen – 1/12
 Both sensitive and specific
 POCT (point of care test) – relatively sensitive but
significant false positive rate and not routinely available in
GP setting
 Seroconversions require serum blood for p24
 HIV +ve needs immediate referral (14/7) to specialist centre
 Any centre testing for HIV must have a quick and effective
procedure of referral put in place
 1-2% false +ve rate
 2 hours for results.
 Venous sample x 2 to confirm (one taken at time of POCT)
 Eligable – MSM, IVDU, Epidemic areas plus contacts,
infected partner.
 Not suitable alone if suspecting seroconversion
Pre-test discussion
Has the person considered having a test
Why are they having the test now
Has the person been tested before
Confidentiality around test result
What is their risk
What is their understanding of HIV and it’s transmission
What are the advantages of knowing
Have they considered what they would do if the result were positive
Who needs to be told the result
Will it have an effect on their employment, life insurance/ other policies
Do they need more time to think it over/ more information
Are there any other tests you might want to consider
Information re ‘window period’
Written information + how they will be informed (face-to-face/ text)
“The worst news you could ever
have given me”
 Prepare your clinic around this consultation
 Patient will need time to express their emotions and
ask questions
 They will need to know what to do now
 Who should they tell
 What does this mean for their partner/ children
 What support do they have when they leave your clinic
 Immediate referral
 Arrange to see them again ASAP
Disease progression
Triple therapy
 Entry inhibitor (CCR5 inhibitor)
 Reverse transcriptase inhibitor (NRTI/NNRTI)
 Protease inhibitor
When to start treatment
 There are arguments for/ against most strategies
 HIV has long natural Hx (adherence/ resistance)
 Antiretrovirals can prevent as well as cure some diseases
 CD4 count of 200 taken as cut off
 Patients on HAART should have undetectable viral loads
 SMART study – randomised treatment (long term) Vs
treat when low CD4
 Once started treatment sudden withdrawal can cause
increased risk of opportunistic infection and vascular
To treat or not to treat
CD4 </= 200
CD4 >350
 Risk of death unlikely before
 Patient usually well
CD4 <50
 Likelihood of disease
progression within 3 years is
 Patient may already be
developing symptoms
 Motivation for lifelong
 Toxicity may cause severe
 May exhaust options before
illness would have occurred
 Heterosexual sex exposure – 0.1 - 0.3%
 MSM anal sex – 0.5 - 1%
 Needle stick injury – 0.3%
 IVDU needle sharing – 0.65 - 1%
 PEP is proven to decrease HIV transmission (probably
around 80% but no studies due to ethics)
 Timing is key – Near 100% if within 1 hour, 50% at one
day, < 1% if >3/7
Starter pack
 Truvada
 Nausea
 Kaletra
 Headache
 Domperidone
 Tiredness
 Loperamide
 Diarrhoea
 Rash
Rule of 3’s!
 HIV +ve patient 1 in 300
 Hep B patient 1 in 30
 Hep C patient 1 in 3
 90% IVDU’s have Hep C
 Needle exchange programmes (HIV rates 5%)
 Much higher in America (IVDU criminalisation)
 Sally is a healthcare
support worker and is
cleaning up a sharps bin
on HIV ward when she
receives a needle stick
injury. She goes home
and returns to work 3/7
later and happens to
mention the incident to
you in passing.
 PEP?
 George is an A&E registrar
and has been asked to
review a knife wound of a
known HIV +ve patient.
The patient is under arrest
and supervised by two
policeman. During the
consultation he becomes
aggressive and violent.
George receives a bite from
the patient
 ? PEP
 Dave is a removals man. He
is moving plastic bags from
a room for an old woman
when he cuts his finder on
something sharp. He
thinks it was ‘one of those
diabetic testing kit
needles’ as the old woman
is a known diabetic. He
knows nothing else about
her PMH. He immediately
presents to A&E.
 ? PEP
 Levine is a 42 year old
white male. In his youth
he was part of a
motorcycle gang. They
all had matching tattoos
done at the time. Now, 15
years later, he has heard
about the risk this might
cause him in relation to
 ?PEP
 Seshi is an ST2 in GUM
medicine. She is due to
take her Part 1 in 1/52.
She is performing a
lumbar puncture on a
known HIV +ve female
when she gets a splash of
CSF in the eye
 ? PEP
 Warren is a 18 year old
MSM. He has never had
penetrative sex before
but attends your clinic
today as he is concerned
about a sexual
experience he had last
night. In your Hx you
establish he had kissing
contact and rimming.
 ?PEP
Top tips for YOU!
 Alarming presentations
 HIV associated conditions (see list)
 AIDS defining conditions (see list)
 If CD4 <200 then should be on PCP prophylaxis
 GP meets HIV (cardiovascular, diabetes etc)
 Check before prescribing
 Low thresh hold to refer
HIV associated
 Oral hairy leukoplakia
 Oropharngeal candida
 Persistent extra inguinal
 CMV ulcers
 TB
Drug interactions
Seborrhoeic dermatitis
Molluscum Contagiosum
AIDS defining
 Pneumocystis carinii pneumonia
 Cerebral abscess (often toxoplasma)
 Non-Hodgkins Lymphoma (60 x more common)
 Cryptococcol meningitis
 Mycobacterium avium complex
 CMV retinitis
Beware the hidden dangers....
 CD4 and viral load
 Open mind to HIV related illnesses
 Consider seroconversion
 Don’t be afraid to test
 When to consider referral for PEP
 HIV in pregnancy

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