British HIV Association Research Articles

CROI 2024 BHIVA working group summary.

The Conference on Retroviruses and Opportunistic Infections (CROI) is usually the most significant HIV conference of the year in terms of basic and clinical scientific output. CROI 2024 in Denver, USA, felt very much back to 'business as usual' following COVID-19 disruptions that had impacted preceding years, but also felt more global and outward- facing. The British HIV Association supports a working group to attend CROI annually and deliver feedback in the UK. This article summarizes the highlights from that meeting.

Impact of omission of routine blood monitoring of stable patients living with HIV during the coronavirus pandemic.

The British HIV Association (BHIVA) guidelines were amended during the coronavirus (COVID-19) pandemic, allowing for less frequent monitoring of routine bloods. We assessed the impact of this on patient outcomes. Between April 2020 and March 2021, routine blood appointments at our HIV clinic were replaced by virtual consultations in 'stable' people living with HIV (PLWH), defined using standard operating procedure (SOP) criteria. All had an undetectable HIV viral load (VL) (<50 copies/mL). Demographic, HIV clinical information, and antiretroviral treatment (ART) data were collated using the electronic patient record (EPR). Blood results from before (baseline) and after (follow-up) the omitted appointment were analysed for each parameter. In all, 791/2395 PLWH were scheduled to have blood tests omitted; 381 were excluded for reasons including not fitting the SOP criteria or presenting to clinic early, and 410 were included in analysis. The demographics of the group were consistent with our whole HIV cohort. HIV VL became detectable in 8/410 individuals (1.95%, range 51-730 copies/mL). VL resuppressed in 6/8 after a median of 29 days. VL remained detectable in two individuals, both of whom remain in care. Routine blood monitoring revealed baseline and follow-up blood parameters that were largely within normal range. Four out of 12 parameters had statistically significant changes but were not considered clinically significant; 59/410 (14.4%) changed ART, most commonly for simplification. For the majority of stable PLWH included in our evaluation, the omission of routine blood monitoring during the pandemic did not have a negative impact on HIV suppression or blood monitoring outcomes. ART switch was uncommon.

British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of pulmonary opportunistic infections 2024.

British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of pulmonary opportunistic infections 2024.

British HIV Association guidelines on the management of opportunistic infection in people living with HIV: Considerations in pregnancy 2024.

British HIV Association guidelines on the management of opportunistic infection in people living with HIV: Considerations in pregnancy 2024.

How are HIV services in the UK currently identifying and managing patients with cognitive impairment? Results of a national survey.

The 2018 British HIV Association (BHIVA) Standards of Care state that people living with HIV should be questioned annually for symptoms of cognitive or memory decline. If symptoms are identified, screening should be considered and services offered if impairment is detected. We examined the availability of services, along with current practices related to the screening and management of cognitive impairment in people living with HIV, in UK HIV services. A survey was distributed via email to all UK HIV services leads on the BHIVA audit mailing list. Questions related to screening practices, referral pathways, and the management of patients with suspected cognitive impairment. Descriptive analyses were conducted on all data returned. In total, 190 surveys were distributed. Of the respondents, 39 (60.6%) stated that they undertook screening for cognitive impairment in their HIV service, and 30 (47.6%) reported not offering a specific service or referral pathway. Awareness of BHIVA screening guidelines was high (49 [84.48%]), yet 15 (30.6%) respondents stated that they were not followed in their service and 41 (71.9%) felt there was a need for training on screening, assessment, and management of cognitive impairment in patients with HIV within their department. Despite no directive, a substantial number of HIV services surveyed are routinely screening patients for cognitive impairment without guidance on when to screen and which screening tools should be used. A UK consensus on screening, along with guidance and training for services, may help to resolve this gap in service provision.

Health economic analyses of latent tuberculosis infection screening and preventive treatment among people living with HIV in lower tuberculosis incidence settings: a systematic review

Introduction: In lower tuberculosis (TB) incidence countries (<100 cases/100,000/year), screening and preventive treatment (PT) for latent TB infection (LTBI) among people living with HIV (PLWH) is often recommended, yet guidelines advising which groups to prioritise for screening can be contradictory and implementation patchy. Evidence of LTBI screening cost-effectiveness may improve uptake and health outcomes at reasonable cost. Methods: Our systematic review assessed cost-effectiveness estimates of LTBI screening/PT strategies among PLWH in lower TB incidence countries to identify model-driving inputs and methodological differences. Databases were searched 1980-2020. Studies including health economic evaluation of LTBI screening of PLWH in lower TB incidence countries (<100 cases/100,000/year) were included. Results: Of 2,644 articles screened, nine studies were included. Cost-effectiveness estimates of LTBI screening/PT for PLWH varied widely, with universal screening/PT found highly cost-effective by some studies, while only targeting to high-risk groups (such as those from mid/high TB incidence countries) deemed cost-effective by others. Cost-effectiveness of strategies screening all PLWH from studies published in the past five years varied from US$2828 to US$144,929/quality-adjusted life-year gained (2018 prices). Study quality varied, with inconsistent reporting of methods and results limiting comparability of studies. Cost-effectiveness varied markedly by screening guideline, with British HIV Association guidelines more cost-effective than NICE guidelines in the UK. Discussion: Cost-effectiveness studies of LTBI screening/PT for PLWH in lower TB incidence settings are scarce, with large variations in methods and assumptions used, target populations and screening/PT strategies evaluated. The limited evidence suggests LTBI screening/PT may be cost-effective for some PLWH groups but further research is required, particularly on strategies targeting screening/PT to PLWH at higher risk. Standardisation of model descriptions and results reporting could facilitate reliable comparisons between studies, particularly to identify those factors driving the wide disparity between cost-effectiveness estimates. Registration: PROSPERO CRD42020166338 (18/03/2020).

Editorial

Editorial

High-level compliance to opt-out HIV testing in the emergency department (ED) of a large teaching hospital using the biochemistry sample as the sample type for HIV screening.

HIV remains a key public health issue. National Institute for Health and Care Excellence and British HIV Association guidance recommends that patients should be offered HIV testing when admitted to hospital or attending emergency departments (EDs) in areas with a prevalence ≥ 2 per 1000. We report a novel method of testing and the first 3-year results from our HIV ED testing programme utilizing biochemistry samples for HIV testing, with the aim of improving uptake while ensuring no changes to clinical practice in EDs. Routine ED HIV testing was implemented on 1 October 2018; it was initially opt-in and was subsequently changed to opt-out on 1 February 2019. HIV testing was added to all ED blood test order sets and was performed on the biochemistry samples of those aged 18-59 years. The age range was extended to include those aged 16+ years on 1 March 2021 along with a move to notional consent. A total of 78 333 HIV tests were performed from an estimated 110 683 attendees who had bloods taken in the same age range, demonstrating an overall 69.5% testing coverage. On implementation of opt-out testing after the first 4 months, the proportion of tests increased (from 57.9% to 69%). After increase in age range to 16+ years and a move to notional consent, the overall testing coverage improved to 74.2%. Of 1054 reactive results, 728 (69%) were known people living with HIV, eight (0.8%) were not contactable, two (0.2%) re-tested elsewhere and three (0.3%) declined a re-test. A total of 259 false-positives were determined by follow-up testing and 50 (4.8%) were newly diagnosed with HIV. An HIV diagnosis was suspected in only 22%, and 48% had never previously tested for HIV. An opt-out HIV testing programme with notional consent and using biochemistry samples within the ED is feasible, acceptable and provides an excellent opportunity to diagnose patients who do not perceive themselves to be at risk or have never tested before.

The British HIV Association national clinical audit 2021: Management of HIV and hepatitis C coinfection.

We aimed to describe clinical policies for the management of people with HIV/hepatitis C virus (HCV) coinfection and to audit routine monitoring and assessment of people with HIV/HCV coinfection attending UK HIV care. This was a clinic survey and retrospective case-note review. HIV clinics in the UK participated in the audit from May to July 2021 by completing an online questionnaire regarding their clinic's policies for the management of people with HIV/HCV coinfection, and by contributing to a case-note review of people living with HIV with detectable HCV RNA who were under the care of their service. Ninety-five clinics participated in the clinic survey; of these, 15 (15.8%) were regional specialist centres, 19 (20.0%) were HIV services with their own coinfection clinics, 40 (42.1%) were HIV services that referred coinfected individuals to a local hepatology service and 20 (21.1%) were HIV services that referred to a regional specialist centre. Eighty-one clinics provided full caseload estimates; of the approximately 3951 people with a history of HIV/HCV coinfection accessing their clinics, only 4.9% were believed to have detectable HCV RNA, 3.15% of whom were already receiving or approved for direct-acting antiviral (DAA) treatment. In total, 29 (30.5%) of the clinics reported an impact of COVID-19 on coinfection care, including delays or reductions in the frequency of services, monitoring, treatment initiation and appointments, and changes to the way that treatment was dispensed. Case-note reviews were provided for 283 people with detectable HCV RNA from 74 clinics (median age 42 years, 74.6% male, 56.2% HCV genotype 1, 22.3% HCV genotype 3). Overall, 56% had not received treatment for HCV, primarily due to lack of engagement in care (54.7%) and/or being uncontactable (16.4%). Our findings show that the small number of people with HIV with detectable HCV RNA in the UK should mean that it is possible to achieve HCV micro-elimination. However, more work is needed to improve engagement in care for those who are untreated for HCV.

A national audit of the management of HIV-2 in adults in the UK.

HIV-2 is rare in the UK. Many UK centres therefore only treat small numbers of people and there are few clinical trials to guide treatment. The British HIV Association (BHIVA) 2010 guidelines for management of HIV-2 formed the basis for this national audit, which aims to describe current practice and adherence to guidelines. All UK centres providing HIV care were contacted via the BHIVA "Members Matters" newsletter, and asked to submit anonymised, retrospective data for individuals living with HIV-2 accessing care at their service. Thirty-five sites responded and data were analysed for 167 individuals. Nearly half of individuals accessed care at one of four large London centres (77/167, 46%).Most people living with HIV-2 have taken antiretroviral therapy (ART) (132/167, 79%). The most common reasons for initiating treatment were clinical disease (34/89, 38%) and pregnancy (11/89, 12%). Most treatment-naïve individuals were initiated on a protease inhibitor based regimen (70/89, 79%). The use of integrase strand transfer inhibitor based regimens has increased over time.A significant minority of patients did not have baseline drug resistance testing performed, despite having a detectable viral load (15/52, 29%). Virological failure occurred in a minority of individuals (21/132, 16%); the most common drug regimen change in this context was the addition of an integrase strand transfer inhibitor (12/26 regimen changes, 46%). Most individuals living with HIV-2 were managed according to national guidance, with key areas for improvement including the choice of ART, drug resistance testing and the management of virological failure. It is hoped that this national audit, performed in conjunction with the updated 2021 BHIVA guidelines will improve the care of individuals living with HIV-2 in the UK.

The impact, effectiveness and outcomes of targeted screening thresholds for programmatic latent tuberculosis infection testing in HIV.

Screening and treatment for latent tuberculosis infection (LTBI) are key for TB control. In the UK, the National Institute for Health and Care Excellence (NICE) and the British HIV Association (BHIVA) give conflicting guidance on which groups of people with HIV (PWH) should be screened, and previous national analysis demonstrated heterogeneity in how guidance is applied. There is an urgent need for a firmer clinical effectiveness evidence base on which to build screening policy. We conducted a systematic, programmatic LTBI-screening intervention for all PWH receiving care in Leicester, UK. We compared yields (percentage IGRA positive) and number of tests required when applying the NICE and BHIVA testing strategies, as well as strategies targeting screening by TB incidence in patients' countries of birth. Of 1053 PWH tested, 118 were IGRA-positive (11.2%). Positivity was associated with higher TB incidence in country-of-birth [adjusted odds ratio, 50-149 cases compared with <50 cases/100 000: 11.6; 95% confidence interval (CI) 4.79-28.10)]. There was high testing uptake (1053/1069, 98.5%). Appropriate chemoprophylaxis was commenced in 100 of 117 (85.5%) patients diagnosed with LTBI, of whom 96 of 100 (96.0%) completed treatment. Delivering targeted testing to PWH from countries with TB incidence greater than 150 per 100 000 population or any sub-Saharan African country, would have correctly identified 89.8% of all LTBI cases while cutting tests required by 46.1% compared with NICE guidance, performing as well as BHIVA 2018 guidance. Targeting screening to higher risk PWH increases yield and reduces the number requiring testing. Our proposed 'PWH-LTBI streamlined guidance' offers a simplified approach, with the potential to improve national LTBI-screening implementation.

1107-P: Is There a Discrepancy between Interstitial Glucose and Laboratory HbA1c in People Living with HIV?

Background: Diabetes is reported to be more common in people living with HIV (PLWH) . There is no internationally agreed screening method for diabetes in PLWH due to reports that HbA1c is falsely low in this group. The ADA recommend a fasting glucose to screen for diabetes in PLWH whilst the British HIV Association recommend measuring HbA1c. Aims: To explore the relationship between HbA1c and interstitial glucose in PLWH. Methods Each participant wore a Dexcom G6 for days and had HbA1c measured. Exclusion criteria included factors affecting HbA1c. HbA1c values were compared to GMI values. Bland-Altman plot method was used to assess the agreement between the measurements. Results: We included 57 PLWH (27 with T2DM, 6 female) , median HbA1c 44mmol/mol (IQR 38-55) , average sensor glucose 7.3mmol/l (IQR 6.4-9.1) . Median completed CGM readings per participant 99% (IQR 92-99) . Bland-Altman plot method (see figure) demonstrates the bias between the two methods is -3.2mmol/mol (95% CI: -1.0 to -5.6) with 95% limits of agreement -14.2 to 20.6. Six participants had an HbA1c 10mmol/mol lower than GMI and 2 had an HbA1c 10mmol/mol higher. Conclusion: This is the first study using CGM to explore HbA1c discrepancy in PLWH. It shows the bias between interstitial glucose and HbA1c is small with moderate agreement between the two methods. Our data support a potential role for using HbA1c to assess glycaemia in PLWH. Disclosure H. Daultrey: None. N. Oliver: Advisory Panel; Dexcom, Inc., Medtronic, Roche Diabetes Care. Research Support; Dexcom, Inc., Medtronic. A. Chakera: None. Funding Dexcom - providing the glucose monitors for the study.

Engaging with HCV reinfection to advance microelimination

Increased access to direct-acting antiviral therapy for the treatment of hepatitis C virus (HCV) has transformed not only individual outcomes for treatment, but also the ambition of health-care systems to eliminate the virus as a public health threat. Services for people living with HIV are well suited to microelimination approaches, 1 The Lancet HIVMicroelimination could be a big deal for HCV and HIV services. Lancet HIV. 2018; 5: e605 Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar , 2 Lazarus JV Picchio CA Byrne C et al. A global systematic review of hepatitis C elimination efforts through micro-elimination. Semin Liver Dis. 2022; (published online Feb 21.)https://doi.org/10.1055/a-1777-6112 PubMed Google Scholar , 3 Martinello M Yee J Bartlett SR et al. Moving towards hepatitis C microelimination among people living with human immunodeficiency virus in Australia: the CEASE Study. Clin Infect Dis. 2020; 71: 1502-1510 Crossref PubMed Scopus (26) Google Scholar with specific elimination targets (eg, those set out in 2018 by the British HIV Association) for well defined subpopulations. In the absence of an effective HCV vaccine for the foreseeable future, individuals with ongoing risk of HCV exposure remain susceptible to reinfection following cure. Reinfection poses not only a challenge to an individual's health but could also risk undermining greater elimination (and microelimination) efforts. Risk of hepatitis C reinfection following successful therapy among people living with HIV: a global systematic review, meta-analysis, and meta-regressionRisk of HCV reinfection following treatment in people living with HIV was highest among MSM and those with recent HCV infection. Continued scale-up of HCV treatment and ongoing HCV screening and treatment of infection in this patient population should reduce viraemic burden and risk of reinfection. Full-Text PDF

Covid-19 First Wave Impact National Survey for HIV Clinicians by Public Health England (PHE), the British HIV Association (BHIVA) and the Children's HIV Association (CHIVA).

IntroductionThis short report describes the results of a survey that was developed by Public Health England (PHE), the British HIV Association (BHIVA) and the Children's HIV Association (CHIVA) and circulated to all UK national health service HIV providers in the UK following the first wave of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2; coronavirus disease 2019 [COVID‐19]) pandemic to assess the impact of the pandemic on HIV clinics.MethodsThe survey was created by BHIVA/CHIVA and PHE and was piloted prior to circulation to all HIV clinics within the UK on 3 July 2020. The survey questions were designed to assess the impact of the first wave of COVID‐19 on HIV clinics and lead/senior HIV clinicians. Clinicians’ responses were collected between 3 July 2020 and 17 September 2020. The survey responses were collated, and non‐statistical analysis was performed.ResultsThe results of the survey confirmed that services had undergone substantial changes, including a shift from face‐to‐face consults to predominantly virtual consultations. Some clinicians’ responses suggested that the first wave had many negative effects on people living with HIV, including their ability to access mental health services.ConclusionThe first wave of COVID‐19 caused significant changes to HIV services within the UK. There was a shift toward the use of technology in healthcare, and results from subsequent clinician surveys carried out since the first wave of COVID‐19 will reflect the ongoing transformation of care towards a more virtual service.

British HIV Association guidelines for the management of HIV-2 2021.

British HIV Association guidelines for the management of HIV-2 2021.

More evidence for worse COVID-19 outcomes in people with HIV

More evidence for worse COVID-19 outcomes in people with HIV

FRAX assessment in people ageing with HIV.

Current British HIV Association (BHIVA) guidelines recommend the use of FRAX for the routine assessment of bone fracture risk in people living with HIV over 50years of age every 3years. Bone mineral density measurement with dual-energy X-ray absorptiometry (DXA) scan is recommended for those with increased fracture risk (FRAX major >10%). Our objectives were to estimate the prevalence of and risk factors for osteoporosis in a population of PLWH aged>50years and assess the utility of FRAX in predicting the presence of DXA-proven osteoporosis in this cohort. This was a cross-sectional study of a cohort of PLWH aged >50years attending the Chelsea and Westminster Hospital and who had a DXA scan between January 2009 and December 2018. FRAX scores were calculated using the Sheffield algorithm. Multiple regression models and Cohen's kappa values were used to assess risk factors for osteoporosis and agreement between FRAX and DXA scan results, respectively. In all, 744 patients were included (92.9% male, mean age 56±5years). The prevalence rates of osteoporosis (at DXA scans) and osteopenia were 12.2% and 63.7%, respectively. FRAX major was >10% in only two patients, while 90/91 (98.9%) patients with osteoporosis had a normal FRAX score. The presence of osteoporosis was significantly associated with low body mass index and estimated glomerular filtration rate (p<0.05). Our results indicate that FRAX scores did not predict the presence of osteoporosis in our population of PLWH over 50years of age and therefore FRAX scores may not be the appropriate tool to define eligibility to perform DXA scans in PLWH.

Abstracts of the 5th Joint Conference of the British HIV Association (BHIVA) with the British Association for Sexual Health and HIV (BASHH), Virtual, 19-21 April 2021.

Abstracts of the 5th Joint Conference of the British HIV Association (BHIVA) with the British Association for Sexual Health and HIV (BASHH), Virtual, 19-21 April 2021.

Themed Posters

HIV MedicineVolume 22, Issue S2 p. 18-23 ABSTRACTS Themed Posters First published: 25 August 2021 https://doi.org/10.1111/hiv.13130Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume22, IssueS2Special Issue: Abstracts of the 5th Joint Conference of the British HIV Association (BHIVA) with the British Association for Sexual Health and HIV (BASHH), Virtual, 19‐21 April 2021August 2021Pages 18-23 RelatedInformation

BASHH 2018 UK national audit of HIV partner notification

HIV partner notification (PN) is a highly effective strategy to identify people living with undiagnosed HIV infection. This national audit of HIV PN is against the 2015 British Association of Sexual Health and HIV (BASHH)/British HIV Association (BHIVA)/Society of Sexual Health Advisers (SHAA)/National AIDS Trust (NAT) HIV PN standards, developed in response to the 2013 BASHH/BHIVA national HIV PN audit. We report significant improvements in the number of contacts tested per index case, likely due, in part, to clearer definitions as well as better ascertainment and reporting. There remains scope for improvement with informing and testing contactable contacts. Recommendations from this audit include further refinement of definitions and development of a national proforma for HIV PN.