HIV management in general practice

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chapter 60 HIV management in general practice

INTRODUCTION AND OVERVIEW

Human immunodeficiency virus (HIV) infection has had, since the early 1980s, a global impact of unprecedented scale, including the decimation of some populations and the retardation of some nations’ development. There have also been revolutions in our understanding of immunology and the pharmacology of anti-retroviral treatments. Researchers in all the sciences have had to change the way they investigate and communicate with affected communities. There have been changes, too, in the way communities are harnessed to prevent and to care, but also in how they can be stigmatised and blamed.

Globally, in 2007, it was estimated that 30–36 million people were living with HIV infection, with a death toll to that point of 1.8–2.3 million.1

General practitioners have always had a central role in the delivery of healthcare to communities (especially marginalised groups) and they have played a key role here as well. Their skills in chronic disease management, their teamwork, their holistic view of health and their long-term relationships with patients and communities all contribute to the care they can bring to the HIV-infected patient.

The HIV epidemic continues to grow and change around the world, influenced by many factors, including but not confined to:

• patterns of behaviour (especially sexual and IV drug use)
• the prevalence of sexually transmitted infections (STIs) in communities—these are important because they aid the transmission of HIV
• politically driven responses that can help or hinder infection rates
• the burgeoning number of new antiviral medications of increasing effectiveness and safety
• the continuing paucity of resources in those very countries with the highest prevalence rates
• the inability so far to develop an effective vaccine.2

How many HIV-infected patients are managed in general practice? The BEACH study in Australia counted 80 consultations per 100,000 and this low figure would probably be seen in other similar developed countries, where it is a predominantly gay male population that is affected.3

However, within all capital cities there are general practice clinics that have a special interest in sexual health and which would see a vastly greater number of HIV-infected patients. In countries where the prevalence of HIV is much higher and health resources are much more scarce, the GP will be seeing many cases of HIV every day. In those countries HIV is high on the differential diagnosis for any chronic health complaint.

For the GP, therefore, different roles are possible, from sole management, through shared care, to early referral. The role chosen will depend on the setting, the interest of the doctor and the resources available.

In resource-poor communities where there are limited antiviral agents available there will be a higher involvement of primary care / general practice and more reliance on traditional healing and so on. However, even here the number of people with HIV who are taking antiviral medications is growing, with the primary care being delivered in a variety of ways.4

In resource-rich communities there is greater complexity of choices and an interest in complementary/integrative measures. Here there will be more centralisation of care to specialist doctors and clinics. Yet even so there is a large burden of poverty within the HIV-affected community and consequent difficulties in gaining access to best care.5

Other important aspects of this disease are:

• the importance of guarding confidentiality and of working with risk groups
• the importance of harm minimisation principles
• the importance of a holistic approach—despite a burgeoning ‘HIV industry’, the GP has to also manage the rest of the patient’s biopsychosocial issues
• the importance of research that can be done at primary care level—this also includes research into psychosocial aspects. Many anti-retrovirals have been trialled with the help of primary care, as this is where the majority of potential participants can be recruited.

HIV AND THE IMMUNE SYSTEM

This disease has a long lead-time, with decline of immunity as the central but not the only aspect. Many comorbidities are possible along the way:

• sexually transmitted infections, hepatitis B, hepatitis C, tuberculosis and other infections (including the opportunistic infections associated with immune deficiency)
• substance abuse problems, including alcohol and/or illicit drug use
• mental health issues, especially depression, but also including cognitive changes later in the evolution of the illness.6

Optimising immune health is therefore an important primary care task, especially among HIV-infected patients. This is important not just from the perspective of improving outcomes and slowing the rate of progression of HIV, but also because of its potential to improve quality of life at the same time. Measures include:

• improving lifestyle in terms of nutrition and exercise
• minimising the use of alcohol, drugs and smoking
• maintaining family and community involvement and the supports they can provide
• promoting a positive outlook, self-esteem and maintenance of hope
• controlling side effects of medications and optimising adherence
• treating depression
• early detection and treatment of STIs
• controlling herpes simplex virus outbreaks
• regular Pap smears
• use of complementary therapies (see below).7

PRIMARY PREVENTION IN GENERAL PRACTICE

HIV transmission is mainly the result of certain behaviours. General practice is well placed therefore to tackle the following:

• reducing at-risk behaviours—this includes promoting safer sex and safer IV use, and antenatal care such as anti-HIV medication prior to delivery
• case-finding and treating other STIs, because the presence of these will enhance transmission of HIV
• education at an individual and population level—not only about how HIV is or is not transmitted (Box 60.1), but also about how health can be optimised
• in resource-rich settings there may be the option of using post-exposure prophylaxis (PEP for occupational or n-PEP for non-occupational exposure)—this is a two or three anti-retroviral drug treatment for 4 weeks following an episode of moderate to severe risk. In the occupational setting this is usually a sharps injury; in the non-occupational setting it usually involves a sexual contact or intravenous drug use
• advocating for change—for example, policy responses to intravenous drug use (needle exchange programs), provision of clean syringes in prisons, and education, regulation and empowerment of sex industry workers.

BOX 60.1 Transmission of HIV

Transmission possible:

• Sexual intercourse without condoms
• Needlestick injury
• Sharing injecting equipment
• Mother to infant (vertical transmission)
• Transfusion

Transmission risk very low:

• Kissing
• Oral sex
• Sexual intercourse with condoms

Transmission not possible:

• Social contact, embracing
• Sneezing/coughing
• Touch (skin surfaces intact), toilet seats
• Exposure to tears, sweat, faeces or urine
• Sharing of eating utensils
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