Why general practice's role in HIV grows in importance
One of the key planks of the Government's sexual health plans is a greater role for general practice in testing Dr Surinder Singh on the challenge
K sexual-health-related morbidity trends are some of the worst in Europe. Although the numbers are not large on a global scale, HIV infection must be regarded as preventable in the UK. Worldwide the situation is profoundly bleak: 40 million people have been infected, half of whom have died. A major report by UNAIDS has highlighted the various, largely increasing trends, in different continents of the world for both HIV infection and AIDS1.
It is increasingly important to regard HIV infection as an incurable infection, often sexually transmitted and one that is rising both in the UK and across Europe2. Significantly, the number of people infected with HIV is rising as is the incidence of other sexually transmitted infections (STIs), for example gonorrhoea, herpes and even syphilis. It is postulated that much of this is happening because people have now forgotten the HIV messages of the late 1980s and risk-activity is on the increase. Additionally, there is no vaccine and best estimates suggest that this will not be available for at least five years. What part does primary care play in all of this in the UK? What do GPs need to know and why?
In the UK there were an estimated 33,200 HIV-infected adults aged 15-59 alive at the beginning of 2000, more than a third of whom do not know they are infected. This latter statistic emanates from the anonymous unlinked HIV testing programme that was established in the early 1990s3. Perhaps most worrying is that the rate of new diagnoses of HIV infections shows no evidence of falling.
Other recent trends include the fact that many people are identified with late-stage HIV infection, especially so in gay men (still), and in black African patients. Approximately a quarter of gay men with HIV infection remain unidentified a high figure considering that this group has been at the forefront of attempting to reduce the effects of HIV almost from the beginning3.
One other epidemiological fact is worth noting and that is the prevalence of HIV is increasing in female heterosexuals in London. For example, in 2000, 85 per cent of HIV-infected women giving birth in London were born in sub-Saharan Africa. Having said this, over the last two years major progress has been made in detecting antenatal HIV infection such that the Department of Health targets have largely been met for example there has been an 80 per cent reduction in mother-to-child HIV transmission since 1999.
What should GPs know?
Following the publication of the National Sexual Health and HIV Strategy in July 2001, an implementation plan was published in July of this year4. The initial strategy was high on aims but low in certain areas such as training and a vision of how sexual health could be optimised taking into account the problems of general practice in the UK such as recruitment and retention of staff.
One of the key aims of the plan is that primary care should be more involved in testing especially important taking into account the numbers of people who have yet to be identified. Can general practice rise to this challenge?
Sometimes it is difficult for GPs to focus on HIV/AIDS within the epidemic of sexually transmitted infections, but there are now strong arguments for HIV testing in general practice; the investigation becomes just another diagnostic tool and every attempt is made to 'normalise' it within everyday practice. There are continued problems of perceptions of confidentiality and the insurance issue, but this should not distract the GP from making a diagnosis in what is a life-changing condition.
In line with this, the department will institute a campaign outlining the advantages of HIV testing (diagnosis, accessibility of treatment, reduced morbidity and mortality) and provide further information for drug-users around now4. There will also be enhanced availability of hepatitis B vaccinations for at-risk groups. While GPs may only be indirectly involved in such directives, it is sensible that we know about such campaigns for queries but also offering hepatitis B vaccination where appropriate.
Additionally, GPs ought to be familiar with the principles of modern-day antiviral therapy, that is combination drugs which are used to reduce HIV activity. In this context compliance (or concordance) with therapy is absolutely fundamental to the treatment because the combination enhances the effectiveness of the drugs. HIV is so changeable that it can build up resistance to drugs very quickly, thus even if a patient stops medication for a short period this may be long enough for the virus to acquire resistance.
This is so important that 'compliance clinics' are now common and it is something that primary care could be involved in.
It is crucial to stress that HIV cannot be cured despite the early optimism that it could be completely eradicated from the body.
Another pointer for GPs is that many of these drugs are new and the range of adverse effects has yet to be fully documented. Thus if a GP, or any other doctor, is about to start new medication for example antibiotics or analgesia it is wise to ask which drugs the patient is taking and whether they have been told to avoid certain medications. In all cases. if there is doubt then ask the specialists first. It is sometimes wise to remember the adage that 'if you don't ask you won't be told'. Having said all this, the effect combination therapy has had on AIDS-related mortality is staggering. Even compared with six years ago the death rate is a mere quarter of what it was5.
The drugs are powerful and are undoubtedly efficacious, but whether this is time-limited or not is unknown. It is also easy for people to be lulled into a false sense of security knowing that morbidity and mortality has reduced, so prevention messages are crucial to the plan.
Recently the concept of super-infection has arisen that is a person with pre-existing HIV infection becomes re-infected with another sub-type. Unfortunately this means treatment is more complex in that the 'new infection' may be resistant to the drugs already being taken. This underlines the continued importance of prevention, safe sex and the need to 'stay safe'.
Why general practice's role in HIV grows in importance
There are now strong arguments for HIV testing in general practice the investigation becomes just another diagnostic tool~
· Early identification of HIV infection, as well as a
re-emphasis on prevention of HIV within the context of trying to reduce general sexually transmitted infections, is a legitimate and expected part of general practice.
· It is sensible that GPs exercise caution in prescribing for patients on combination therapies for the simple reasons of drug interactions and adverse events. If in doubt consult with the specialist or specialist pharmacist to ensure safe prescribing.
· It is possible that a person with pre-existing HIV infection can become
're-infected' (super-infection) this underlines the central importance of prevention messages and 'staying safe'.