How I...achieved 97 per cent MMR vaccination uptake
HIV is increasingly managed as a chronic disease, with many more patients surviving for longer periods. As a result, the emphasis of care has become shared between specialist centres and primary care. In the second of our two-part series, Dr Sara Madge, Dr Philippa Matthews, Dr Surinder Singh and Dr Nick Theobald advise on what GPs need to know.
In many ways, looking after someone with HIV is no different from looking after those with other chronic conditions. The specialist centres are responsible for initiating and monitoring antiretroviral therapies (ART) and remain responsible for prescribing ART.
The role of the GP may vary a great deal depending upon the health of the patient. In addition, the relationship the GP has with the patient, and the relationship between the patient and their specialist team, will affect how the patient uses primary care.
For many health problems, all that is needed is advice, reassurance or simple treatment.
Nevertheless, there are times when immediate referral for assessment is more likely to be appropriate.
It is important for GPs to have active communication with specialist HIV clinics. They should expect to be written to regularly, and should be prepared to notify specialists in return if there are significant changes in the patient's management or circumstances.
Physical problems caused by HIV infection are significantly less common in the diagnosed patient now that ART is widely used. A patient with HIV who presents with symptoms might have:
·problems that relate to HIV disease (check the most recent CD4 count)
·side-effects of ART
·an unconnected problem.
You may be able to take the first steps to distinguish which of these is the case. A recent CD4 count that is comfortably above 200 makes HIV-related problems less likely. Check which antiretrovirals the patient is on, and check for side-effects in the BNF.
Conditions requiring urgent referral
Serious conditions due to HIV disease affect patients with CD4 counts below 200 cells/µL (except TB). Symptoms that require careful assessment include:
·visual (even if apparently minor, such as floaters)
·progressive or acute neurological problems.
Side effects of ART are sometimes serious or even life-threatening check which medication the patient is on.
Many HIV-related problems are also common in patients who do not have HIV, for example shingles and seborrhoeic dermatitis. Management of such conditions is generally the same, and the GP is likely to be familiar with treatments.
But immunosuppressed patients may require longer treatment than other patients. The table on the right presents a brief guide to managing HIV-related problems.
Current advice should always be based on the most recent edition of the Green Book (Department of Health (1996): Immunisation against infectious disease), unless practitioners are informed otherwise.
In general, live vaccines should be avoided. All inactivated immunisations are safe. Adults with HIV should be offered:
·influenza immunisation each year; and
hepatitis B testing and immunisation as
·hepatitis A immunisation for men who have sex with men.
In addition, they may be offered pneumococcal immunisation.
Caring for people on antiretroviral therapy
ART has had an enormous impact on morbidity and mortality from HIV disease in those countries that have been able to afford the drugs.
New drugs and strategies are continually being developed. Your patient (particularly if recently infected) has a good chance of living with their HIV for decades.
ART limits HIV replication. It has had an enormous impact on morbidity and mortality from HIV disease in the UK.
New drugs and strategies are continually being developed.
Antiretroviral drugs are classified into four groups, according to where and how they act in the replication cycle of the virus. They are:
·nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
·non-nucleoside reverse transcriptase inhibitors (NNRTIs)
·protease inhibitors (PIs)
Because HIV readily mutates as it replicates, resistance to single anti-HIV drugs develops very readily. This means that currently three or more drugs are used in combinations, and that adherence to drug regimens is essential.
Monitoring of ART is primarily by viral load. Clinicians are also able to access information on the resistance of the strain of HIV in an individual patient and this helps guide drug choice.
After ART has started, the combination of drugs may be changed according to any side-effects. These will often be minor but can include more serious conditions such as hyperlipidaemia, diabetes and lipodystrophy (a syndrome characterised by redistribution of body fat).
Adherence to ART is very important. If people with hypertension miss out their medication for a short period it will still be effective when they restart. Unfortunately this is not the case with ART.
Adherence to a long-term drug regimen is one of the biggest challenges to those who live with HIV as well as to those who support them. The timing of the medication through the day may be complex, and it is hard to sustain a regular regimen without losing motivation or even simply forgeting doses.
Monitoring adherence is something the primary care team can do well. When patients are seen, the GP or practice nurse should assess and monitor how they are coping with taking their medication and whether they are missing doses. Patients need to understand the reasons behind the requirement for optimal adherence as well as the possible consequences of missed doses.
If they discontinue or repeatedly miss doses, try to explore the reasons for this. In some areas HIV specialists can arrange adherence support.
Sara Madge is a GP in north London, honorary lecturer in the department of primary care and associate specialist at the Royal Free Centre for HIV Medicine
Philippa Matthews is a GP in Birmingham and also works in the West Midlands deanery GP unit as programme director in sexual health and HIV
Surinder Singh is a GP in Deptford, south London, and a former chair of the RCGP HIV working party
Nick Theobald is associate specialist in HIV/ genitourinary medicine at Chelsea and Westminster Hospital and Imperial College, London
British HIV Association (2003) guidelines for the treatment of HIV-infected adults with antiretroviral therapy:
Check for drug interactions on:
Check for side-effects on:
The above article is an adapted abstract from the authors' booklet 'HIV in Primary Care' published by the Medical Foundation for AIDS & Sexual Health (MedFASH).
The free booklet is available:
·By E-mailing enquiries.medfash
·By phoning 020 7383 6345