What is the role of primary care in the identification and treatment of people with HIV? Here are some practical tips for GPs
CREDIT: This is an edited version of an article that originally appeared on Medscape
The history of HIV is fascinating: once a stigmatised disease that equated to a death sentence, the condition is now so treatable that clinicians have to think about managing coexisting menopause and frailty of old age.
Regarding the characteristics of HIV infection, here are a few basics to remember:
A healthy cluster of differentiation 4 (CD4) count is around 500–1600 cells/mm3
Significant immunosuppression begins at a CD4 count of approximately 200 cells/mm3
In untreated HIV infection, the average drop in CD4 count is 50–70 cells/mm3 per year.
General practice plays an important, if overlooked, role in the identification and care of people with HIV. This article provides 10 top tips for primary care practitioners, covering identification, testing of people at risk or with symptoms, associated care, and effective use of clinical systems.
Determine the Prevalence of HIV in Your Area and Offer Testing Accordingly
Published in December 2022, the most recent government report estimated that there were 4400 people with undiagnosed HIV infection in England in 2021, a reduction from the estimated 6700 people in 2018. For the NHS to reach its aim of zero HIV transmissions by 2030,these numbers need to reduce further—after all, someone who is undiagnosed cannot take steps to reduce transmission.
Primary care practitioners in areas of high or extremely high HIV prevalence (in which two or more people per 1000 people aged 15–59 years have been diagnosed as HIV positive) should be offering and recommending an HIV test:
To all new patients (ideally, under a funded enhanced service)
When doing blood tests for any other reason, unless the patient has already had an HIV test in the preceding year.
If HIV prevalence is extremely high (five or more people per 1000 people aged 15–59 years have been diagnosed as HIV positive), the British HIV Association and NICE recommend that clinicians should consider offering a test at every consultation. However, this suggestion seems too impractical and resource-intensive to be implementable in primary care.
Test, Test, Test
Indicator conditions are conditions that have an associated undiagnosed HIV seroprevalence of greater than one in 1000 and are therefore cause for suspicion of HIV—this is because they usually either share an aetiology or transmission route with HIV, or are a marker of immunosuppression.
Many indicator conditions, such as unexplained pneumonia, lymphadenopathy, weight loss, fever, and chronic diarrhoea, cervical dysplasia, and subcortical dementia are seen regularly in primary care.
Children of HIV-positive mothers should also be tested for HIV unless they have already had a negative test after finishing breastfeeding—a parent’s refusal to allow such a test is a child protection issue.Other high-risk children should also be tested, such as recent asylum seekers, children born abroad in high-prevalence countries, and ‘looked-after’ children.
Window Periods
Some HIV tests are antibody based, and it can take up to 90 days for a person to make enough antibodies to trigger a positive test after they are exposed to infection, depending on the test being used.
Therefore, although it is acceptable for a clinician to offer an HIV test fewer than 90 days after potential infection, the patient must repeat the test after the window period to confirm a negative diagnosis. Many laboratories now use combined antibody/antigen tests that shorten the window period to as little as 45 days,but it is safest to use a standard, recommended window of 90 days—unless the particular test used by the local laboratory is known.
Be Vigilant for HIV Seroconversion
HIV seroconversion presents with symptoms that are common presentations in primary care, including fever, malaise, lethargy, and sore throat, and it is unrealistic to offer a test to every person who presents with, for example, a sore throat in winter.
However, primary care practitioners see maculopapular rashes less often, and such a rash—particularly in combination with a fever or sore throat—should prompt a clinician to discuss recent risk with a patient and offer them a test, as it is especially suggestive of seroconversion.
Patients diagnosed during seroconversion can start antiretroviral therapy (ART) immediately (sometimes on the day of diagnosis), and clinicians can discuss transmission with them. This makes it a win for both the patient and public health.
Record antiretrovirals in computer systems, even though they are not prescribed in Primary Care
In primary care, it is good practice to record all long-term drug prescribing in secondary care as ‘hospital issue’ on clinical computer systems. This should allow many systems to automatically identify a patient’s eligibility for vaccinations and therapeutics where appropriate, such as for flu or COVID-19, and—crucially—to flag any interactions between antiretrovirals and other drugs.
UK guidance clearly states that diagnoses of HIV should be shared with the patient’s GP, and that the potential harms of nondisclosure should be regularly reviewed when a patient refuses to share this information, so clinicians will hopefully know about most of their patients with HIV and be able to do this accordingly.
The University of Liverpool’s HIV drug interactions website is a very useful resource to check drug interactions. It is used by HIV consultants and so using it, and documenting this in the notes, is a medicolegally safe thing to do.
Drug Interactions and Contraception
Drug interactions can be a particular issue for women with HIV who are considering contraception, in which case the relevant Faculty of Sexual & Reproductive Healthcare guidance should be consulted.
Women taking enzyme-inducing antiretrovirals are likely to be restricted to intrauterine contraception or the depot injection and should be offered a copper intrauterine device (IUD) if they need emergency contraception, or a double dose of levonorgestrel if this is unacceptable, unsuitable, or unavailable. Use of double dose ulipristal is not recommended and the effectiveness of a single dose of ulipristal compared with a double dose of levonorgestrel is unknown.
Leaving aside drug interactions, HIV itself is generally not a contraindication for contraceptives. The only exception to this rule is that the risks associated with insertion of an IUD outweigh the benefits if a person’s CD4 count is below 200 cells/mm, presumably because of pelvic infection risk.
For more information on HIV in primary care, read the full article on Medscape
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