BHIVA Guidelines Research Articles

1.0 Introduction

1.0 Introduction

4.0 When to start

4.0 When to start

6.0 Supporting patients on therapy

6.0 Supporting patients on therapy

7.0 Managing virological failure

7.0 Managing virological failure

British HIV Association guidelines for the management of hepatitis viruses in adults infected with HIV 2013

British <scp>HIV A</scp>ssociation guidelines for the management of hepatitis viruses in adults infected with <scp>HIV</scp> 2013

Loss to follow up within an HIV cohort

BHIVA guidelines recommend that all ARV‐naïve and stable on‐treatment patients are monitored at least 6 monthly [1]. Studies have shown that loss to follow up (LFU) not only worsens outcomes [2] but has increased potential for onward transmission. Case notes of 1275 HIV patients registered under our care up to January 2011 were examined for attendance within the previous 6 months. 788 (61%) patients had not been seen within the previous 6 months. Reasons for non attendance were identified. These are outlined below: Patient group Number Deceased 61 Transferred care to another HIV clinic 455 Moved out of the UK 54 Lost to follow up ‐ no means to contact 130 Lost to follow up ‐ eligible for recall 88 76% of the 130 LFU whose demographics were further examined were of Black African ethnicity, 54% female, 51% of single marital status and 48% of patients had been taking ARVs at the time of LFU. Interestingly, 53% of patients were lost to follow up within 1 year of diagnosis. The LFU patients (88) that had a local GP and a registered current address were sent recall letters. A small number of patients reengaged with care as a result of this action, some having not attended for over 5 years. Partner notification led to a number of new diagnoses in these cases. Failure to respond led to subsequent letters inviting them to clinic and finally a letter to their GP informing them of non attendance. In September 2011, a new recall system using Lillie Electronic Patient Records (EPR) was introduced to promptly recognise if a patient had not attended for care as planned. Prior to this, recall was a manual process carried out by the Health Advising Team. We conclude that within our cohort we had a particularly mobile group of patients; 455 (36%) transferring care to another clinic within the UK, 54 (4%) moving out of UK. 76% of the LFU group being of Black African ethnicity highlights the ongoing problem of retention of care in this group. Further exploration is needed to identify additional issues besides housing and immigration that lead to LFU. Furthermore, the disportionate number of patients (53%) disengaging with services within 1 year of diagnosis should encourage HIV services to provide additional support within this time period to reduce LFU. This study highlights the need for robust recall systems within clinics to identify those individuals not engaging with services or not attending for routine monitoring. These may be easier to implement with the increasing use of EPR. An audit of the recall system is planned in September 2012 to re‐examine loss to follow up rates after its implementation.

1.0 Introduction

1.0 Introduction

8.0 Antiretroviral therapy in specific populations

8.0 Antiretroviral therapy in specific populations

5.0 What to start

5.0 What to start

British HIV Association guidelines for the treatment of HIV‐1‐positive adults with antiretroviral therapy 2012

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of adults with HIV infection with antiretroviral therapy (ART). The scope includes: (i) guidance on the initiation of ART in those previously naïve to therapy; (ii)support of patients on treatment; (iii) management of patients experiencing virological failure; and (iv) recommendations in specific patient populations where other factors need to be taken into consideration. The guidelines are aimed at clinical professionals directly involved with and responsible for the care of adults with HIV infection and at community advocates responsible for promoting the best interests and care of HIV-positive adults. They should be read in conjunction with other published BHIVA guidelines.

4.0 Screening and monitoring of HIV‐positive pregnant women

4.0 Screening and monitoring of <scp>HIV</scp>‐positive pregnant women

P15 Are we following BHIVA guidelines in newly diagnosed HIV patients?

BackgroundBHIVA published guidelines in 2008 on the treatment of HIV infected adults. These guidelines were used as a basis for optimal patient care.AimsTo audit the following against BHIVA guidelines: (1)...

Changing management of HIV in pregnancy: service development following the introduction of universal antenatal screening

Universal antenatal screening for HIV was introduced in 2000 with the aim of screening 90% of the population and offering interventions to those infected; aiming to reduce the incidence of...

British HIV Association guidelines for antiretroviral treatment of HIV‐2‐positive individuals 2010

British HIV Association guidelines for antiretroviral treatment of HIV‐2‐positive individuals 2010

Time taken to undetectable viral load, following the initiation of HAART

The notes of all HIV patients in Sheffield, registered at the Department of Genitourinary Medicine at the Royal Hallamshire Hospital, who had initiated HAART in 2005 and 2006, were audited. The aim was to determine what percentage of these patients acquired an undetectable viral load within 24 weeks and whether this was greater than 75% in accordance with the BHIVA guidelines. Twenty-nine (78.4%) of the 37 patients who were initiating treatment for the first time had an undetectable viral load after 24 weeks.

British HIV Association guidelines for the treatment of HIV‐1‐infected adults with antiretroviral therapy 2008

The 2008 BHIVA Guidelines have been updated to incorporate all the new relevant information (including presentations at the 15th Conference on Retroviruses and Opportunistic Infections 2008) since the last iteration. The guidelines follow the methodology outlined below and all the peer-reviewed publications and important, potentially treatment-changing abstracts from the last 2 years have been reviewed. The translation of data into clinical practice is often difficult even with the best possible evidence (i.e. two randomized controlled trials) because of trial design, inclusion criteria and precise surrogate marker endpoints (see Appendix). The recommendations based upon expert opinion have the least good evidence but perhaps provide an important reason for writing the guidelines to produce a consensual opinion about current practice. It must, however, be appreciated that such opinion is often wrong and should not stifle research to challenge it. Similarly, although the Writing Group seeks to provide guidelines to optimize treatment, such care needs to be individualized and we have not constructed a document that we would wish to see used as a ‘standard’ for litigation.

BHIVA guidelines on HIV and chronic hepatitis: coinfection with HIV and hepatitis C virus infection (2005)

(1) All HIV-positive patients should have serum markers for hepatitis B checked (HBsAg, anti-HBc and/or antiHBs) tests within a month of diagnosis [II]. (2) All those negative for hepatitis B markers should be immunized and anti-HBs checked at 12 weeks. Patients failing to respond to a conventional course of 20 mg vaccine should received booster doses and/or a repeat vaccination cycle with the 40 mg dose. Response to vaccine may be reduced if the CD4 count is less than 500 cells/mm [I]. (3) Those patients with a CD4 counto200 cells/mm not on ART should receive combination therapy first and with immune recovery, subsequent immunization. (4) Following successful immunization, anti-HB levels should be checked yearly and booster doses of vaccine should be given to those with an anti-HB levelo100 im/ L [IV]. (5) Persons who fail to seroconvert to HBV vaccine and are at continuing risk of HBV infection should have annual HBV markers performed (HBsAg and anti-HBc) [IV]. (6) All patients who are anti-HBc positive but HBsAg negative are at risk of HBV reactivation. HBV markers including HBV-DNA should be rechecked annually or if the liver function tests (AST/ALT) become abnormal [II]. (7) All HIV-infected persons should have serum markers for HBV checked before antiretroviral (ARV) therapy is commenced and then reassessed at least once a year. Decisions on appropriate ART combinations can then be made [IV].

BHIVA guidelines on HIV and chronic hepatitis: coinfection with HIV and hepatitis B virus infection (2005)

BHIVA guidelines on HIV and chronic hepatitis: coinfection with HIV and hepatitis B virus infection (2005)

Guidelines for the management of HIV infection in pregnant women and the prevention of mother‐to‐child transmission of HIV

Aims of the guidelines These guidelines, drawn up by a multidisciplinary group of clinicians and lay workers active in the management of pregnant women infected with HIV, aim to give up-to-date information on interventions to reduce the risk of mother to child transmission of the virus. The evidence on the use of interventions to prevent mother to child transmission of HIV has been graded according to the strength of the data as per the definitions of the US Agency for Health Care Policy and Research [1]. Weighted evidence on the use of combination antiretroviral therapy (ART) for the treatment of HIV infection per se is presented in the BHIVA guidelines for adults [2,3]. The highest level evidence (i.e. randomised controlled trials (RCTs) or large, well conducted meta-analyses) is only available for formula feeding, prelabour caesarean section and zidovudine monotherapy. The need to treat mothers for HIV infection has led to the widespread use of ART in pregnancy which in turn results in new questions such as how to deliver when the mother, on therapy, has no detectable plasma viraemia with the most sensitive assays. In addressing many common and/or difficult clinical scenarios in the absence of ‘best evidence’ the guidelines rely heavily on ‘expert opinion’. Recommendations for management are given in the section on clinical scenarios, and summarized in Table 3. An expanded version of these guidelines with an appendix on safety and toxicity data is available on the BHIVA website http://www.bhiva.org. The authors are available to discuss individual cases.

BHIVA treatment guidelines for tuberculosis (TB)/HIV infection 2005

AL Pozniak, RF Miller, MCI Lipman, AR Freedman, LP Ormerod, MA Johnson, S Collins and SB Lucas, on behalf of the BHIVA Guidelines Writing Committee Chelsea and Westminster NHS Healthcare Trust, London, UK, Centre for Sexual Health and HIV Research, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, London, UK, Royal Free Hospital, London, UK, Cardiff University School of Medicine, Cardiff, UK, Blackburn Royal Infirmary, Blackburn, Lancashire, UK, HIV i-Base, London, UK, Department of Histopathology, GKT School of Medicine, St Thomas’ Hospital, London, UK