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Managing patients with HIV

Consultant genitourinary physician Dr Colm O'Mahoney addresses the issues raised by GP Dr Sally Whittet, and underlines the importance of GP involvement in care

Consultant genitourinary physician Dr Colm O'Mahoney addresses the issues raised by GP Dr Sally Whittet, and underlines the importance of GP involvement in care

1 GPs are encouraged to offer HIV testing in primary care, so hopefully patients will receive an earlier diagnosis, but in a non-specialist setting. Two of our positive patients have refused to engage with an HIV clinic, so we manage them. Do you see this as the trend? If the CD4 count is more than 350, is there any need for specialist input?

The simple answer is no. However, some of the benefits of attending a specialist unit – although fringe – occasionally mean a lot to the individual. For example in my own clinic, we employ a complementary therapist who offers aromatherapy and reflexology during HIV clinic time, and some patients make a specific appointment just to come and see her. Cheshire and North Wales Body Positive also have a presence in the HIV clinic and some patients find it enormously beneficial to talk to these highly knowledgeable individuals on an informal basis. For example, it may help a young woman who has recently discovered she is HIV positive to meet another woman who also went through a similar scenario years before and is now remarried to a young HIV negative man. So, for some patients who do not need peer or emotional support there is no specialist input needed with a CD4 count greater than 350, and I expect this to be a growing trend.

2 We have scant experience of contact tracing, and confidentiality is our motto. As we get more involved in HIV care we will inevitably have to breach confidentiality to protect other patients. If we know a husband is positive and he won't tell his wife, can you clarify our legal position?

This issue is more a theoretical fear than a reality. It is incredibly uncommon to find a HIV positive patient who will not disclose this to their untested partner. It may take a week or two for them to come to terms with the issue themselves and, indeed, I had one heterosexual man who discussed with me the option of not telling his partner for three months. During that time he did not have unprotected intercourse with her, and at the end of the three months he told her and she had an HIV test. This saved her the stress of worrying about the three-month window period, and miraculously she was HIV negative.

However, the GMC is explicit about confidentiality and there is clear-cut advice. If a patient refuses to tell their sexual partner, every effort should be made to persuade them to do so. If it becomes obvious that they have not, the physician must inform the patient that he or she will tell the partner. The advice here is specific – if you are going to break confidentiality you must tell the patient that you are going to do so. It is wise to discuss it with another doctor, an expert if possible, to share and dilute the blame if there is a fuss. It could, however, get more complicated if you do not know who the partner is, but I would not let this issue put you off, as the scenario described above is very rare.

3 What are the guidelines for vaccinations? What should we avoid and what should we offer routinely? Please include advice about children, travellers, and gay men (and BCG).

Live vaccines are contraindicated in most HIV positive patients. The BNF has a section on HIV and vaccines, and the British HIV Association (BHIVA) has the latest edition of recommendations on its website.

• Never use BCG. • Never use cholera CVD103-HgR, polio oral, typhoid-Ty21a, and influenza nasal. • If not severely immunosuppressed (CD4 count greater than 200) then MMR, varicella and yellow fever may be recommended.

This is dangerous territory and should be done in consultation with a specialist unit or after careful discussion of the website information with the patient.

4 Highly active antiretroviral treatment (HAART) interacts with many drugs. What tips can you offer to enable us to prescribe safely? Is there a good website? What are the common prescribing errors?

The ultimate website is the Liverpool pharmacology group at Liverpool University www.hiv-druginteractions.org. It has printable charts of the three classes of HIV drugs. It is mainly the protease inhibitors that have the most serious interactions. Most are not immediately obvious and it is essential to consult before prescribing. For example, even the simple antihistamine astemizole should not be co-administered with any protease inhibitor. Lovastatin or simvastatin are also contraindicated.

5 Can you advise on the best way of managing or preventing the long-term effects of HAART? One consultant has told me they have some patients dying of premature CVD now rather than AIDS.

Luckily, the newer forms of HAART have few side-effects and most of them do not increase cardiovascular risk. Many of the protease inhibitors do increase cholesterol and LDL levels and many patients from the early therapies do, indeed, have increased rates of atheroma and cardiovascular disease. However, many of these were heavy smokers and, at the time, it was not relevant to introduce dietary changes and cessation of smoking as these patients had a limited life span. However, the scene has changed and I now emphasise to newly diagnosed patients that they have every likelihood of having a normal healthy lifespan, as long as they:

• have not been infected with a resistant virus• can tolerate the initial side-effects of HAART and keep going• can take the drugs as prescribed and not miss a single dose (studies shows that the key to successful suppression of HIV is taking every single dose – less than 98 per cent adherence is asking for trouble)• are taking care of themselves with a healthy lifestyle – not smoking, no excess alcohol, eating a proper diet• are extremely cautious when taking any other medication, prescribed or otherwise, which could interfere with HAART efficacy (for example, St John's wort).

6 Medfash published a book HIV in Primary Care (which can be ordered free of charge from medfash.org.uk). Do you recommend this book to GPs and patients? Do you recommend other sources of information?

I still think the best book for general practice on HIV/AIDS is The ABC of AIDS edited by Mike Adler, published by BMJ Press. It is regularly updated and I still refer to it.

7 A gay man presented to our nurse with a rash on a Friday afternoon. Syphilis and a seroconversion illness were on her list of differentials. How important is it to diagnose HIV at this point, and why? What are the tips for diagnosing a seroconversion illness, and what tests should we request – with what degree of urgency ?

Unfortunately, syphilis or HIV are seldom considered in the differential diagnosis of the multitude of conditions that can present like them. Basically, pyrexia of unknown origin, rash, lymphadenopathy, muscle aches and pains, fatigue, shingles, worsening psoriasis, intractable or giant molluscum contagiosum are all common, but are definitely a feature of HIV and are largely missed.

Gay men are still in the highest risk group for HIV and syphilis. The unwell gay man does need a full sexual health screen, and most of this can be done in general practice. It is critical that a clotted sample is taken and blood, and sent with a request for syphilis, hepatitis B and C, HIV, toxoplasma, CMV and Epstein Barr virus: if lymphogranuloma venereum is considered, antibodies for chlamydia can also be requested. All this can be done on a single sample. Even in district general hospitals, most laboratories do HIV testing on a daily basis. This individual would have a result by Monday afternoon if the blood was sent Friday evening to the laboratory. In terms of pre-test counselling, the nurse should discuss the fact that these tests need to be done. If someone is HIV positive they need to know it, both for their own sake and for the people in their lives for whom this might have big implications.HIV seroconversion illness is not in itself an emergency, although some of the seroconversion reactions can be extreme and very debilitating. There is no evidence that commencing anti-HIV therapy during seroconversion illness has any positive impact on the disease, either short term or long term. The BHIVA recommends that patients who are undergoing a seroconversion illness, who are adamant that they want anti-HIV drugs, should be entered into one of the trials doing this, as the issue is still unclear. If the laboratory records a positive HIV result it would only be proper for the practice to tell the patient about the result and there should be immediate (within several hours) access to the local GUM/HIV service for further discussion if the patient wants that. All the pre-test counselling in the world makes hardly any difference. It is the post-test care and attention that are of critical importance.

8 Recently a five-year-old HIV positive girl was admitted with chicken pox, and was quite poorly. How should we manage shingles and chicken pox?

Shingles and chicken pox in an HIV positive patient can be more aggressive and antiviral treatment should be started within 72 hours. Most texts say parenteral treatment is necessary (seven days IV and three days oral). However in these days of few beds and MRSA, is an acute ward the best place for open wounds in an immunosuppressed patient? Most undiagnosed HIV positive patients eventually develop shingles. It is an indicator of a depressed immune system and the thought of HIV should at least be entertained.

9 What are the red flags? In what clinical situations should we refer urgently?

Chest and neurological problems are ones that can go badly wrong quickly. In diagnosed HIV positive patients we rarely get sudden onset urgent complications, as we can usually follow the CD4 count and have them on HAART at around 300. The big dangers are undiagnosed patients who present sick with pneumocystis pneumonia or intracranial lesions. These patients often have a CD4 count less than 50 and the situation can deteriorate rapidly. Usually they have been unwell for months, if not years, with minor problems and it takes intuition to consider HIV in the differential of an acutely ill patient with pneumonia or neurological signs indicating a brain lesion.

10 What is the best contraception for positive women, and what advice should we give to women who wish to conceive?

If her partner is HIV negative, condoms are essential as well as other contraception. The problems arise from the liver enzyme inducing action of both protease inhibitors and the non-nucleoside reverse transcriptase inhibitors (NNRTIs). Specialist advice is needed. The BHIVA website bhiva.org has a section on reproductive and sexual health that gives advice. Basically COC, EVRA, POP and implants are best avoided. There are no known adverse reactions with DMPA, LNG-IUS and IUCDs. Although it is only a theoretical risk, a higher dose of levonorgestrel for emergency contraception is considered necessary. So two doses (3mg) are taken instead of one.

If she is considering pregnancy that should be taken into account before she starts on HAART and a regimen used that is considered non-teratogenic. If she is already on HAART consideration should be given to changing it if there is a high risk of inducing defects.

11 I have recently diagnosed HIV in a woman who is due to start her nursing training in the autumn. Does she have to disclose her status to her college? Would you advise her to change her plans?

No, she does not have to disclose her status to her college. When she qualifies as a nurse and applies for a job she does have a professional duty to inform her employers of her status. Most occupational health units in hospitals have forms that explore known illnesses, and this would have to be disclosed at that stage. The 2005 edition of the Blue Book (The management of health, safety and welfare issues for NHS staff) covers this area. Employers or the individual can contact the UK Advisory Panel for Healthcare Workers Infected with Blood-Borne Viruses (UKAP) on 020 8200 6868.

In the UK, experience of disclosure is usually very favourable, particularly in healthcare settings. Occupational health departments are extremely careful to ensure there is no discrimination against HIV positive medical or nursing staff. Obviously, exposure-prone procedures are inappropriate, but there should be relatively little impact on this nurse's career.

Colm O'Mahoney is a consultant physician in genitourinary medicine at the Countess of Chester Hospital NHS Trust, Chester, and is a member of the executive committee of the BHIVA

Competing interests None declared

Take-home points

• HIV positive people with a CD4 count more than 350 can usually be safely managed in primary care

• Many interactions with HAART are not obvious – for example, some statins and antihistamines

• There is no evidence anti-HIV therapy during seroconversion illness has any impact on the disease

• GPs have been taught that live vaccines are contraindicated in HIV positive people, but some, including yellow fever, may be given if there is not severe immunosuppression: visit bhiva.org for guidelines

• HAART suppression requires more than 98 per cent adherence

• Many older protease inhibitors did increase cholesterol and LDL levels, but newer HAART does not increase CVD risk

what i will do now

Dr Whittet comments on the answers to her questions

• I will add www.hiv-druginteractions.org to my favourites

• I will revisit The ABC of AIDS by Dr Michael Adler, but I still think the Medfash book is unbeatable

• I will consider giving yellow fever vaccine to patients with good immunity

• I will concentrate more on lifestyle issues. I have a tendency to collude with my patients and sympathise with their addictions if they have unpleasant illnesses. I will get tough!

• I will also write to the positive patients and offer them a primary care health check, because they miss out on GP care and many don't even get their blood pressure tested

• I will be bolder with gay men. I will offer safe sex advice routinely because they are in the highest risk group for catching syphilis and HIV

Dr Sally Whittet is a GP in London

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