The British HIV Association (BHIVA) conference in October hosted a fascinating debate about the pros and cons of HIV testing in Accident and Emergency (A&E) departments.
Dr Duncan Churchill, of the Royal Sussex County Hospital in Brighton, said that a third of the estimated 65,000 plus people with HIV in the UK are undiagnosed and don’t know they have the disease. People diagnosed late (‘late presenters’) have 10 times more chance of early death than those diagnosed early enough for treatments to be effective.
The experience of antenatal HIV testing of nearly all pregnant mothers in Britain showed that ‘opt out’ testing clearly works, he said. This has meant that the number of babies now born with the disease in this country has gone down to just a few each year.
But we need to test men at risk of the disease, both straight and gay, who do not come forward for testing and are reluctant to access health services.
A significant majority of people who come to GUM departments for testing or treatment for other sexually transmitted infections (STIs) leave the clinic without receiving HIV testing.
And GPs don’t want to do HIV testing because they argue they are not paid to do it and they say they don’t have the time or facilities.
‘Opt out’ testing would, “change the culture of HIV testing” in the UK, he said.
The cost of each HIV test in A&E would be as low as £3, Dr Churchill said, making it extremely cost effective.
Lisa Power, head of policy at the Terrence Higgins Trust, said that THT was in favour of targeted testing rather than blanket testing.
There are very limited resources in the NHS and there was also very little evidence that opt out testing in A&E was cost effective or practical.
HIV prevalence is much higher in London than the rest of the country, she said, and there should be intensive and targeted community HIV testing aimed at high risk groups, such as gay men and Africans.
Even at £3 a test, the cost of HIV testing in A&E could be more than £44 million each year at least and the money could be better spent testing elsewhere.
“Waiting for HIV test results is a considerable strain for the patient,” Power said: “There is a serious lack of understanding and prejudice against HIV in the rest of the medical profession.”
There would also be serious problems of confidentiality and follow up at A&E and the money would be better spent educating all medical staff about HIV.
Dr Churchill retorted that each new HIV infection costs as much as half a million pounds in NHS costs during the life time of the patient and HIV testing in A&E would save a lot of money in the long run.
At the end of the debate there was a vote amongst the 600 BHIVA delegates and there was a majority against the motion advocating routing HIV testing in A&E.
HIV clinics only deal with a third of HIV problems, a survey revealed this summer. Dr Richard Hardy, of University College London, told the AIDS Impact Conference in Marseilles, that his study of over 900 HIV patients revealed a high prevalence of unreported and untreated physical and psychological problems.
This found that things like feeling worried, depressed and in pain were symptoms in over a half of patients and they rarely spoke to their HIV doctors about such issues.
The self completed questionnaire found that 70 per cent of patients had experienced fatigue in the previous 7 days, 66 per cent had felt sad, 61 per cent had difficulty sleeping and 53 per cent had experienced severe diarrhoea, sexual dysfunction and high pain levels.
These rates are similar to those experienced by terminal cancer patients, Dr Hardy said, and being on HIV treatments did not lower the number or extent of these symptoms. Psychological stress is often associated with poor HIV drug adherence as well as higher rates of unprotected sex.Patients are enduring a lot of distressing symptoms which are rarely presented at HIV clinics and are often poorly managed.
Quality of Life studies measured suicide ideation in the study and 31 per cent of people who switched HIV therapy reported having suicidal thoughts with multiple switchers having even higher suicide ideation. “Is the reason for the depression poor adherence or vice versa?” community activist Mr Gus Cairns asked.
African HIV positive men who have sex with other men (MSM) face double or even triple amounts of stigma and prejudice in British society, according to Dr Jane Anderson, of East London’s Homerton University Hospital.
Cultural and religious differences in African communities make for more difficulties for men who have sex with men and there are only 40 studies on MSM from the whole of Africa, Dr Anderson told the AIDS Impact conference this summer.
A recent study conducted in east London found difficulties coming out to families and fellow Africans as well as difficulties integrating into either African communities or gay networks in the UK. There are high, but undisclosed, rates of racism among gays and homophobia among Africans. Whereas Africans make up just 1 per cent of the British population, in 2005 they made up 46 per cent of people in England, Wales and Northern Ireland receiving HIV care.
This is probably an underestimate, Dr Anderson said, and Africans who are gay and HIV positive face a double or triple jeopardy in this country.
Already stigmatised in their own communities, they often have nowhere to go for support, and find it impossible to disclose their status to family or friends. This leads to living a double life which in itself leads to more depression.
And if the gay HIV Africans are tied up in the asylum system in this country, they also can face deportation to or violence in their own countries as well fears that HIV drugs will not be available for them back in Africa.
Medically, African MSM are also late to test for HIV and late to present for treatments, Dr Anderson said, making them more at risk of rapid disease progression or early death.
Diagnosing people with HIV across the world is now the key to fighting the epidemic, Dr Kevin de Cock, of the World Health Organisation (WHO), told the autumn BHIVA conference.
The 2005 G8 summit at Gleneagles in Scotland had promised universal access to antiretroviral (ART) drugs for all people worldwide that needed them by 2010, but can we have universal access without universal testing?
There are several serious restrictions on widespread HIV testing, not least concerns about civil liberties, the uncertain natural history of HIV and lack of effective treatment. But testing all pregnant mothers, as in the UK, can reduce mother to child transmission (MTCT) to virtually zero. This proves how effective universal testing can be, Dr de Cock argued.
Research has shown just how life saving antiretroviral therapy (ART) can be. In the US it is estimated that at least 3 million years of life have been extended in just 10 years of ARVs. But the main problem has been diagnosing and treating people early enough for therapies to work. In the UK a third of people infected with HIV do not know they have the virus and are undiagnosed. Experience has shown that late diagnosis adversely affects treatment outcomes. But diagnosis can have a positive side, not just by starting treatments. After diagnosis most HIV positive people do make an effort to prevent the infection of others.
A recent study found that a third of men who have sex with men (MSM) in 3 English cities hadn’t ever been tested for HIV before and over 40 per cent of MSM diagnosed HIV positive had a sexually transmitted infection (STI) in the last year.
So there is a silence about HIV still, even in the gay community itself.“The activist slogan from the early days of the epidemic –‘Silence equals Death’ has not lost its relevance.”
Dr de Cock said screening for HIV has been shown to save money as well as lives in the long term. In the US, routine screening is now recommended for all adults and this has received little opposition. But in Britain, routine HIV testing hasn’t happened, mainly for financial reasons.But should we be proposing testing for all, Dr de Cock asked? And should people be tested against their will or without support and counselling services? It is fine to argue for universal treatment access but even in the UK we don’t have universal access because so many people do not know their HIV positive status.There is a clear resistance to change inside what Dr de Cock called the ‘Aids establishment’ but we have to normalise the clinical diagnosis of HIV and normalise HIV testing to have any chance of success against the worldwide epidemic.
The law is being used “recklessly” in this country in criminal prosecutions for HIV transmission, according to the editor of NAM’s AIDS Treatment Update (ATU).
Speaking at the AIDS Impact Conference in Marseilles in July, Edwin Bernard said that criminalisation of HIV has now become the hot issue in this country.
Between 2001and 2007 there have been 15 prosecutions and 12 convictions of people with HIV for ‘reckless’ transmission of the virus, Mr Bernard reported.
Prison sentences of between 2.5 and 9.6 years have been handed down to those convicted.
Nine white British, 4 black Africans and 2 white Europeans with HIV have so far been prosecuted.
Of the cases, 10 were for male to female transmission, 2 female to male and 3 male to male.
In order to be prosecuted successfully for Grievous Bodily Harm (GBH) in this country, the defendant has to be HIV positive and be proved ‘reckless’ in foreseeing possible harm done by his or her actions.
The law itself is being used recklessly in such cases, Mr Bernard said, and as a blunt instrument in a misguided way.
The criminal law is focusing on innocent victims versus guilty perpetrators and is increasing HIV stigma and discrimination.
A 2005 survey by the UKC (UK Coalition of People Living with HIV and Aids) found that a third of people thought that criminalisation of HIV would increase transmission rates and a half of those questioned thought it would make no difference.
“Is disclosure of status now a duty for all HIV positive people?” Mr Bernard asked.
A 1998 government White Paper suggested that only ‘intentional’ HIV transmission should be prosecuted.
“Now the law is suggesting that HIV positive people are 100 per cent responsible for keeping their infection to themselves.”
The law rewards ignorance and gives a false sense of security, Mr Bernard said, and is responsible for spreading fear and paranoia among HIV positive people in this country.
And the demand for scientific evidence by the police and courts in such cases means that medical confidentiality in HIV and sexual health is no longer above the law.
Fear is also leading to mistrust of the police and legal system by HIV positive people, he said, and there have been anecdotal reports of police pursuing HIV positive people and searching mobile phone records, diaries and address books.
The police are even conducting ‘fishing’ expeditions to gain evidence, Mr Bernard alleged.
Lisa Power, head of policy at Terrence Higgins Trust (THT), said the law was ‘an ass’ on the issue.
It was setting up supposed good HIV positive people versus bad HIV positive people, was not helping anyone and was making stigmatisation of people living with the virus even worse.
Dr Anna Marie Geretti, of the Royal Free Hospital, said that she had been asked to give scientific evidence in court.
“Phylogenetic evidence cannot prove that Person A gave the same virus to Person B,” she said.
The Crown Prosecution Service (CPS) has been conducting a consultation on the issue and was due to report earlier this year and a Department of Health (DH) consultation was due to be published this summer.
Mr Bernard said government inaction on effective HIV prevention campaigns was being glossed over by targeting HIV positive people for prosecution.
Dr James Collier, of Chelsea and Westminster Hospital, said that clinical notes were now no longer legally privileged and confidential medical records could be requested by the courts.
Even the proper use of condoms did not preclude a prosecution for criminal ‘recklessness’ he said.
Both UNAIDS and the World Health Organisation (WHO) had proposed minimal use of criminal law in controlling HIV transmission, he added.
British HIV doctors are facing a dilemma of whether to treat failed asylum seekers in this country, it became clear this month.An Abbott Pharmaceuticals debate at this autumn’s BHIVA conference found that HIV specialists are divided about whether they should treat HIV positive asylum seekers, where to go for help and whether they would be breaking the law.
Dr Mervyn Tyrer, of the Royal Free Hospital London, chaired a BHIVA debate with an expert panel discussing case studies involving HIV patients facing deportation from the UK.The first case study was of a 38 year old Zimbabwean single mother of 2 children who had been living in the UK for 9 years but who was facing imminent deportation. She had both HIV and TB.
A big majority of delegates voted that she should be treated for both conditions but existing NHS rules say she is eligible for TB treatments but not for HIV treatments.
Dr Surinder Singh, of the Royal Free and University College Hospitals, said the patient should be treated for both conditions.
Ms Josephine Namusisi, of Positive East, said clinicians should do what is in the best interests of the patient. Miss Nicky Perry, of Brighton and Sussex University Hospitals, said: “We would want her to feel safe and secure. Treat her TB and HIV, give her adherence support and involve the whole clinics’ team.”
Miss Jennifer Swan, of Newham University Hospital, said hospitals are now following up treated Africans and trying to get money from patients for HIV treatments.
Ms Namusisi said that public health was an issue in this case but also she is a mother of two young children and what about their future if she is deported?
Dr Tyrer said that nationwide a staggering 40 per cent of new HIV patients are late presenters, with a CD4 count of less than 200 and asked what GPs could do to improve this?
Dr Singh said that in his borough, Barnet, only 2 GPs on the whole local list tested for HIV and he felt GPs should do more.
Ms Perry said we shouldn’t bash GPs too much but encourage them with education and HIV training.“This is everyone’s problem,” she said.
Dr Tyrer asked whether we should be dispersing HIV out into primary care and asked if our GPs are competent enough to treat HIV?“I fear not,” Dr Singh replied.
The delegates then voted on what the Zimbabwean lady should be treated with and the voting was split.
Some felt she should be given the best possible treatments here but others felt treatment decisions should be made on what drugs could be available for the woman when she was sent back to Zimbabwe.
Ms Namusisi said the woman had no hope of decent treatments at home in Zimbabwe as it was only available to a few thousand people there. Dr Tyrer then asked delegates if UK doctors felt they were confident in addressing immigration issues among their HIV patients? A big majority voted no. And few knew where to send such patients for advice. Nicki Perry said we should involve community groups and advocates more in such cases. And Josephine Namusisi said that the worry of being deported meant that for many Africans with HIV in the UK, immigration issues are more important for many patients than their own health. Dr Tyrer said doctors have a duty to advocate on their patients’ behalf.
A fascinating session brought up many ethical and legal dilemmas for HIV doctors.
Should they ignore NHS rules and treat people the government says they shouldn’t? Should hospitals be chasing up patients for the money to pay for HIV drugs?
And could doctors face disciplinary or even legal action for acting on their conscience and in the best interests of their patients instead of strictly obeying NHS rules?
news on the side
HIV mums ‘now have safe and healthy babies’
The debate among doctors on which treatments to use for HIV positive pregnant mothers is still very much open, the October BHIVA conference heard. Dr. Annemek de Ruiter, of Guy’s and St Thomas’ Hospital London, highlighted the pros and cons of various HIV drug combinations and monotherapies and the possible dangers of using certain antiretroviral drugs in pregnancy. There was still a slightly higher rate of HIV transmission for vaginal delivery than for elective caesarean section (ECS), Dr de Ruiter said, and a one-and-a-half times higher risk of premature delivery for mums on HAART rather than on monotherapy.
The UK HIV transmission rates in pregnancy are now very low, due to almost universal HIV testing in pregnancy, and are now down to a rate of less than 0.1 per cent.
Sexual health screening for all advised
Dr. Ade Fakoya, of Newham General Hospital in London, told the BHIVA meeting that with increasing numbers of people now living with disease long term, HIV should be considered as a chronic manageable disease rather than as a death sentence. There is a great need now to focus on STIs (sexually transmitted infections) and on general sexual health, Dr Fakoya said, and it is important that all HIV patients be fully screened annually for STIs, Hepatitis A, B, C and syphilis. Only 48 per cent of UK clinics offer such screening annually and 39 per cent at initial presentation. www.bhiva.org.
New clues on why HIV causes AIDS
After 25 years since the first recognised cases of AIDS, and 23 years since the first description of HIV, we still remain unclear about exactly how and why the disease is so virulent, Dr. Louis Picker, of Oregon Health and Science University in the USA, told the BHIVA conference.
HIV replication is very fast but takes more than 10 years before the disease becomes manifest. Dr Picker said his research had looked at SIV (Simian Immunodeficiency Virus) in macaque monkeys and studied how HIV and SIV exploit and deplete CD4 cells.
Rapid depletion of CD4 memory cells creates a greater dependency on new CD4 cell production. And if the production of new CD4 cells cannot keep up with their depletion or infection by HIV, or SIV, then the immune system breaks down catastrophically.
“AIDS is a disease of central memory cell renewal and maintaining precursor uninfected memory cells slows down disease progression.”
The research offers the possibility for new drug targets that prevent CD4 cell depletion and therefore disease progression, Dr Picker said.
First-Ever British HIV Association (BHIVA) Garden Unveiled
at the BHIVA Autumn Conference
The permanent garden feature, providing a haven of relaxation for people with HIV and HIV healthcare teams alike, will be donated to an HIV hospice or clinic post the event.
The British HIV Association (BHIVA) and Merck Sharp & Dohme Ltd (MSD) today unveiled the first ever ‘BHIVA Garden’ at the BHIVA Autumn Conference, taking place in London from 11-12 October 2007. Providing a calm and uplifting garden space for delegates at the BHIVA Conference, the garden will live on after the conference, with HIV hospices and clinics invited to apply for the permanent garden feature.
“Slow progress on HIV vaccine search”
There has been little success in the search for an HIV vaccine, Dr. Barry Peters, of Guy’s and St Thomas’ Hospital, told the autumn BHIVA conference.
Only one in six of people with the virus in need of treatments are now receiving them, he said, which makes the search for an effective HIV vaccine all the more important.
The fact that HIV has such an effective shield and changeable viral envelope makes the search even more difficult.
“The results after millions of dollars investment and thousands of volunteers later were very poor.” Dr Peters said he’d looked at X Ray crystalography of the virus’ structure.
“I was quite shocked at how beautiful it looked at the molecular level,” he said: “Like a very cautious handshake that becomes a bear hug.” But so far, vaccine approaches have failed and the search is likely to be a very long one. “Like the weather forecast - it’s impossible to predict,” Dr. Peters concluded.
“We need to treat both Herpes & HIV”
The Herpes Simplex Virus (HSV) is very common among HIV positive patients and is often a marker of high risk sexual practices, Dr Anna Marie Geretti, of the Royal Free and University College Medical School. HIV and HSV often infect together at the same place and we need to treat both. HSV active sites are also often sites where HIV enters the body and CD4 cell infected sites are also often the sites of HSV replication. HSV infection is often associated with age, gender and ethnic group, Dr Geretti said, and highly active antiretroviral therapy (HAART) greatly improves the immune response and treatment of the disease.
HIV in Adolescents: Dosing in the dark?
The mortality rate for young people growing up with HIV in the western world is now very good, Dr. Patricia Flynn, of St Jude’s Research Hospital, Tennessee, said.
There are two main groupings of adolescents with HIV, those who had survived HIV from childhood and those catching HIV from high risk behaviour in their teenage years.
Many young people living with HIV have gone through a succession of antiretroviral therapies (ARVs) since birth. The consequence of this is multiple resistance mutations and many young patients in her clinic having to take mega HAART of five to seven different HIV drugs each day.
There is no targeted pharmacokinetic (PK) or drug doses for adolescents, so “We’re dosing in the dark.” HIV positive children grow up slower, shorter and lighter. A recent study found that they have 18 per cent less height and 34 per cent less weight than children of the same age who don’t have HIV.
Young people growing up with HIV are prone to anxiety disorders, attention deficit disorders as well as behavioural and mental health problems. There are also problems with sex. HIV teenagers have more sexual partners than their HIV negative peers, they start having sex younger and they are often abused as children. There is also a high amount of drug and alcohol abuse, feelings of hopelessness and depression. Disclosure of HIV status is a major concern and many find that HIV stigma is the worst thing they have to cope with, Dr Flynn said.
