The Docs
HIV care –A GP perspective
The Docs
City centre Manchester
6500 patients
3 GP partners, 2 practice nurses,1 HIV
specialist nurse, 1 CBT therapist
(1day/wk)
217 patients with HIV (200 pts
asthma/hypertension 100 diabetics!)
Almost all HIV patients=MSM
Route of infection and ethnicity of HIV
positive attendees at the Docs, 2009
Infection Route
2
Ethnicity
5
MSM
178
(96%)
1 3
White
180
(97%)
MSM
Injecting drug use
Heterosexual
1
White
Black Caribbean
Black African
Other/Mixed
HIV Intelligence system, Liverpool John
Moores University, 2009.
Access to services and shared care
• 80% of the Docs’
patients travel less than
two miles to access the
Docs
• Most patients were also
seen in a hospital clinic,
but 8% solely used the
Docs in 2009
Other
WITG
SALG
3%
5%
3%
NMG
43%
HIV Intelligence system, Liverpool John
Moores University, 2006 - 2009.
MGP
8%
MRIG
38%
Specialist HIV nurse/Lead GP
HIV Screening at The Docs
Same day tests every Wednesday
177 HIV tests performed Jan-Nov 2010
6 tests = HIV positive
Full STI screens offered
On site treatment chlamydia/GC
Immunisation Hep A/B to at risk groups
New Diagnosis of HIV
nurse led
HIV test repeated
Full STI screen inc Hepatitis
LFTs/U+E’s/cryptococcal
Ag/toxoplasma/CMV
CD4/viral load
New Diagnosis
What happens next?
Patient seen by SWJ in 1/52 to discuss
results
BHIVA guidelines + patient choice
If patient well/results good (CD4>350)
repeat in 1/12
Ongoing discussion about when/which
hospital patient wishes to be referred to
Decision to refer-patient choice+/- falling
CD4/rising viral load
BHIVA recommendations for
starting therapy
Primary HIV infection
Treatment in clinical trial
or neurological involvement
or CD4 <200 cells/mL >3/12
or AIDS-defining illness
Established HIV infection
CD4 <200 cells/mL Treat
CD4 201–350 cells/mL Treat as soon as possible when patient ready
CD4 351–500 cells/mL Treat in specific situations with higher risk of
clinical events
CD4 >500 cells/mL Consider enrolment into ‘when to
start’ trial
AIDS diagnosis Treat (except for tuberculosis
when CD4 >350 cells/mL
Ongoing monitoring of patients with
HIV
CD4/viral load bloods
Lipids/LFTs/U+E/glucose/OGTT
BP checks
Convenient for patients to attend surgery
before work for bloods
SWJ faxes results to hospital before
appointment
Primary care services
nurse
Smoking cessation
CVD risk calculation using QRISK
Renal function using ACR/eGFR
STI screen
Smears
Annual Flu jab
H1N1
5 yearly pneumococcal vaccine
CBT trained nurse practitioner
Primary care services
GP
Diagnosis and treatment of other illnesses
(HAART drugs on computer system-warns
of interactions)
Rationalising non HAART meds
Reduction programme benzo/z drugs
Chronic disease management
(renal/bone/lipid/hypertension)
Diagnosis/mx mental health problems
HIV workload at The Docs
2010 177 HIV tests performed -6 positive
July-Dec 2010 599 appointments in
surgery
Sexual health screening and treatment
Increasing incidence of Anal Ca,
osteoporosis, IHD, palliative care issues
Ageing population-developing
HT,Diabetes, COPD
HIV-New Diagnosis
PA dob 1972
21/12/09 BA –unwell 3/52. 5day h/o red
rash, slightly itchy on trunk/limbs.
MSM, always uses condoms. Nurse.
Adv to have same day test
Sick note 1/52
HIV New Diagnosis
PA
23/12/09 HIV and p24 positive
Results discussed
Sick note 2/52
5/1/10 CD4 329
Viral load 310578
13/1/10. s/b BA. Long chat. Arr occ health.
Sick note 11/1/10-1/2/10
HIV New Diagnosis
PA
3/2/10 staged return to work –feeling ok
CD4 499
Viral load 238998
17/2/10 s/b BA back at work full time.
Tired.
31/3/10 flu/pneumococcal
Hep A immune/syph neg
Viral load 179324
HIV New Diagnosis
PA
12/5/10 CD4 390, viral load 138302
9/6/10 not feeling good CD4 319/viral load
147526
11/6/10 –pt would like referral to
Withington GU
26/7/10 seen in clinic. Truvada/Etravine
started
Long Term Care HIV+ve
BN dob 1959 HIV+ve 1998
Sep 03
Mar 04
Apr
July
Sep
Oct
ulcerative gingivitis –adv bloods
candidal oesophagitis –adv bloods
CD4 328 –adv attend hosp
took HAART for 3 days -sfx
candidiasis mouth, CD4 200
abdo pain/diarrhoea GP arr admit
didn’t go in!
Sharing care BN
2005 attended 21 appts-oral thrush/D+V
2006 attended 8 appts –chest infections
2007 attended 4 appts –chest infections
Taking HAART-good response
Tenofovir/FTC/atazanavir/Ritonavir
Sharing care BN
Feb 08 - MAU subacute encephalopathy
Extensive Ix -HIV encephalopathy
Nursing home June 2008
Woke up! all possessions gone
Sep 08 –back to work at casino
Nov 08 –bus pass/DLA
Apr 09 – smoking cessation
(pneumothorax)+COPD
Sharing care BN
Aug 09
Sep
Nov
Mar 10
Apr
May
Sep
Oct
Casino medical-unfit for duties
Non attendance at hosp
move care to Hope
move back to MRI
Incapacity benefit stopped.
Supporting letters = decision upheld
benefits reinstated on appeal.
pincer movt –agrees to restart HAART
Sharing Care
BN
6/1/11 infective exacerbation COPD
Admitted MRI –discharged same day
20/1/11 continued deterioration COPD
Stops HAART
SW/Nursing package
14/2/11 999 A+E-discharged same day,
phonecalls from neighbours
Palliative care list
15/2/11 misses Hospital appt (transport fails to
arrive)
Shared Care BN
2011 -10 encounters –visits/phonecalls,
involving all 3 GPs and specialist nurse
Coordination of nursing/SW/hospital
Palliative care BUT rapid deterioration –
emailing GU consultant to get assessment
18/2/11 –improvement with antibiotics,
less SOB
Issues
Non attendance
Co-morbidities –COPD
Compliance with HAART
Social implications-work/benefits/DLA
Rapid deterioration –not due to HIV?
Difficult to get medics interested
General issues for discussion
Importance of communication between
primary/secondary care
HAART interactions –a minefield for GPs
unaware of HIV status/medicines
Chronic disease mx
Increasing age of people with HIV –in next
5yrs 50%>50yrs
The Docs
Dr Barbara Allan
GP partner/trainer
55-59 Bloom Street M1 3LY
Barbara.allan@nhs.net
