Lighten up, Phil, and stop the whining
sexual health in general practice
As HIV infection rates continue to climb, GPs are being asked to share the care of those affected in the fourth article of our sexual health series, Dr Olwen Williams offers practical advice on testing and treatment
of those affected in the fourth article of our sexual health series, Dr Olwen Williams offers practical advice on testing and treatment
With more than 50,000 people now living with HIV in the UK, secondary care specialists are encouraging patients to see their GP rather than rely solely on genitourinary and infectious disease services and with good reason. The year 2003 saw the greatest number of new HIV diagnoses made in the UK and that was just the tip of the iceberg.
It's estimated that one in three diagnoses remains unrecognised. This, and the improving survival rate, means GPs are now more likely to have an HIV-infected patient on their list than at any time before. So what does the GP need to know?
Testing for HIV in primary care
Primary care is frequently the first port of call for patients concerned about their sexual health and HIV, but many are discouraged by their GP when it comes to HIV antibody testing. It seems many still believe that having a record of a HIV test result in their GP notes will compromise their ability to obtain life insurance.
This is not the case; the Institute of insurers has jointly issued a statement with the BMA that states: 'Insurance companies should not ask whether an applicant for insurance has taken an HIV or hepatitis B or C test, had counselling in connection with such a test, or received a negative test result.
'Doctors should not reveal this information when writing reports and insurance companies will not expect this information to be provided. Insurers may ask only whether someone has had a positive test result, or is receiving treatment for HIV/AIDS, or hepatitis B or C.'
Pre-test discussion and informed consent are prerequisites together with a risk assessment. The pre-test discussion should involve the pros and cons of testing, the three-month window period that exists between exposure and the development of antibodies to HIV and the need to repeat if the patient presents within this period.
Many patients want an instant result and the wait can be quite distressing, so support during this period is important. Also ensure they know when and who will be giving their result.
In the case of a patient receiving a negative test, they may need health promotion advice.
For those receiving a positive diagnosis, you should: seek the advice of a HIV specialist and outpatient appointment, arrange a repeat HIV test to confirm the diagnosis, give information on support groups and HIV.
Advice on safer sex and avoidance of sharing of injecting equipment, razors and toothbrushes is important and reassurance that HIV is not acquired through social contact is essential.
You should also advise the patient to think carefully about whom they tell about their diagnosis in the first few weeks.
With antenatal HIV antibody screening now occurring across the UK, many women are receiving their positive
result in the second trimester of pregnancy.
Not only do they have to cope with being positive themselves but face the prospect that their sexual partner and unborn child may also be positive.
Intervention with antiretroviral therapy (ART) in pregnancy from week 24 with a combination of three drugs and caesarean section with avoidance of breast-feeding has reduced vertical transmission from 25 per cent to around 1 per cent in developed countries.
Pregnant women on ART have a higher risk of late miscarriage and premature labour but the reason for this has not been elucidated. Long-term follow-up of HIV-positive babies who were exposed to ART in utero and for the first month of life has not thrown up any major long-term sequalae from being exposed to these drugs, but as they themselves will be exposed to ART later in life, research on HIV-negative offspring needs to be carried out over the long-term to truly identify any complications.
The newly-diagnosed HIV patient needs baseline tests to evaluate their immunological status and the viral load of HIV, which determines whether intervention with ART and/or primary prophylaxis against opportunistic infections such as pneumosystis carinii pneumonia (PCP) is necessary.
Hepatitis B and C status should be established, as being positive for either of these blood borne viruses would alter timing and type of therapeutic intervention.
An HIV specialist should instigate these investigations and interventions. In individuals who present without signs and symptoms of AIDS, two sets of CD4 and viral load measurements within around six weeks of each other are necessary to give the clinician and patient some idea of the patient's immunological status.
Most patients will have their bloods checked on a three-monthly basis, whereby a pattern of how their disease is progressing will become apparent. Some individuals will drop their CD4 count rapidly -fast progressors and others have a gradual decline over many years slow progressors, on average between 50-100 cells per annum.
The normal CD4 range for non-HIV infected individuals is 750 to 2,500, but drops to 350 in the second trimester of pregnancy. Patients with CD4 cell counts below 300 and viral loads above 30,000 may be considered for ART, as will individuals with rapidly falling CD4 counts and those who develop AIDS-defining illnesses.
Starting therapy is a major milestone for the patient; it involves the commitment to take medication on a daily basis with adherence to therapy of a minimum of 95 per cent of prescribed tablets for the rest of their life.
In-depth discussion about treatment side-effects, adherence and monitoring is essential. It is also likely that lifestyle changes will be needed to prevent the increased risk of cardiovascular disease, diabetes and body fat changes which occur with ART.
Most clinicians prior to commencing ART will arrange a viral resistance test, which checks the sensitivity of the virus to the various ART drugs.
There are currently 19 licensed ART drugs available with others in the pipeline. Since 1997, the combination of three or more drugs from at least two different classes of drug groups has dramatically improved patient survival and quality of life.
Therapy aims to bring the viral load to 'undetectable' (below 40 copies/ml) and raise the CD4 count above 350 and into the normal range if possible. The commonest combination currently used in the UK is Combivir (two nucleoside reverse transcriptase inhibitors zidovudine and lamivudine in a single tablet given twice daily) in combination with a non-nucleoside reverse transcriptase inhibitor such as efavirenz, a single 600mg tablet taken at night.
There are many alternative combinations and as new drugs become available, especially with once-daily formulations, there is a move to simplify regimes. Clinicians are guided by clinical trials, which have compared various regimes as regards their potency and durability.
The first ART regime may be the only regime a patient has for many years if tailored to suit them and if they are well-motivated. For a variety of reasons patients will fail therapy.
Reasons for treatment failure
The commonest cause is lack of adherence to therapy. Unfortunately when doses are missed viral suppression does not occur, the virus mutates and becomes resistant to the drug it has been exposed to intermittently.
The first signs of this may be transient blips in the viral load, which eventually rises. At the point the viral load is greater than 1,000 copies, resistance testing can be carried out and the mutation pattern will guide the subsequent ART regime.
Drug interactions can also lower the serum levels of ART causing failure. This is an important area especially when considering instigating any medication in primary care. The department of pharmacology at the University of Liverpool offers a drug interaction interactive chart on its website which is user friendly and covers all groups of drugs including recreational drugs.
It's worth noting that the efficacy of the oral contraceptive is reduced with some ART, as pregnancy may not be desirable for some women.
Most of the ART drugs have side-effects; nausea, vomiting and diarrhoea being the commonest experienced. Most clinicians will issue antiemetics and antidiarrhoeal drugs with the ART regime.
Efavirenz is associated with CNS side-effects, including headaches and vivid dreams. The protease inhibitors such as indinavir can cause metabolic abnormalities abnormally high lipid levels and diabetes. Patients should have fasting lipids and urine testing for glucose every three months; intervention with an appropriate statin and/or fibrate may be necessary.
This increases the cardiovascular risk; therefore other factors such as blood pressure should also be monitored.
Dr Olwen Williams is a consultant genitourinary physician at Wrexham Maelor Hospital, Wrexham, and chair of the British Association for Sexual Health and HIV's adolescent and sexual health special interest group
·A record of a negative HIV test in the patient's notes does not compromise their ability to obtain life insurance
·CD4 cell counts below 300 and viral loads above 30,000 may be
considered for ART
·Hepatitis B and C status should be established in newly-diagnosed HIV patients, as being positive for either of these alters timing and type of therapeutic intervention
·The most common cause for
treatment failure is lack of adherence
·Issue antiemetics and antidiarrhoeal drugs with the ART regime to overcome the most common side-effects
·The Department of Health has produced an excellent
90-page booklet with MedFASHH called HIV in Primary Care to help GPs recognise and deal with common problems associated with HIV testing, identification of signs and symptoms and management. Copies have been issued to PCTs in England free of charge. Copies are available to download off the MedFash website www.medfash.org
·Guidelines on treatment advice and lifestyle changes are available at the British HIV Association website: www.bhiva.org
·For information on drug interactions, visit the University of Liverpool website: www.hiv-druginteractions.org
·Information for newly diagnosed patients is available on: www.aidsmap.com
·Advice on HIV testing and insurance issues is available on the BMA website: www.bma.org.uk