1. The Docs HIV care –A GP perspective

2. 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

3. HIV Intelligence system, Liverpool John Moores University, 2009. Route of infection and ethnicity of HIV positive attendees at the Docs, 2009 Infection RouteEthnicity

4. HIV Intelligence system, Liverpool John Moores University, 2006 - 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

5. Specialist HIV nurse/Lead GP

6. 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

7. 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

8. 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

9. BHIVA recommendations for starting therapy Primary HIV infection Treatment in clinical trial or neurological involvement or CD4 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

10. 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

11. 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

12. 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

13. 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

14. 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. MSM, always uses condoms. Nurse. Adv to have same day test Sick note 1/52

15. 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

16. 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

17. 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

18. Long Term Care HIV+ve BN dob 1959 HIV+ve 1998 Sep 03 ulcerative gingivitis –adv bloods Mar 04 candidal oesophagitis –adv bloods Apr CD4 328 –adv attend hosp July took HAART for 3 days -sfx Sep candidiasis mouth, CD4 200 Oct abdo pain/diarrhoea GP arr admit didn’t go in! didn’t go in!

19. 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

20. 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

21. Sharing care BN Aug 09 Casino medical-unfit for duties Sep Non attendance at hosp Nov move care to Hope Mar 10 move back to MRI Apr Incapacity benefit stopped. May Supporting letters = decision upheld Sep benefits reinstated on appeal. Oct pincer movt –agrees to restart HAART

22. 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)

23. 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

24. 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

25. 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

26. The Docs Dr Barbara Allan GP partner/trainer 55-59 Bloom Street M1 3LY Barbara.allan@nhs.net