Monday 1st December  was World AIDs Day  and OHL would like to thank our members, the GPs and their Practice staff in Lewisham,  for their ongoing support in increasing HIV testing. Their efforts in Lewisham have identified 11 new HIV diagnoses and successfully re-engaged 12 patients, of the 260 South Londoners who have entered HIV treatment since Nov 2018 with the Elton John AIDS Foundation Social Impact Bond 1.  We will continue to opportunistically add on HIV tests for patients where appropriate and this is especially important during the second wave of COVID, as of the 24 patients diagnosed/ reengaged with treatment, the average CD4 was 264, below the 350 level which puts them at risk of opportunistic infections.

(CD4 cells, also known as T cells, are white blood cells that fight infection and play an important role in your immune system. A CD4 count is used to check the health of the immune system in people infected with HIV (human immunodeficiency virus). HIV attacks and destroys CD4 cells)

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Due to the success in Lewisham, the Elton John AIDS Foundation has commissioned OHL to continue with the Social Impact bond project this year. The aim of the project is to ensure patients with HIV are diagnosed as early as possible and patients remain on treatment, to reduce their morbidity and mortality as well as providing savings for healthcare systems.

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World AIDs Day is also a great opportunity to celebrate what London has already achieved as a fast track city2 in “Getting to Zero” so that by 2030 we have:

ZERO new infection, ZERO deaths & ZERO stigma

 

London has already achieved its UNAIDS 90-90-90 goals, as 95% of people living with HIV infection are diagnosed; 98% of people diagnosed are receiving treatment, 97% of people receiving treatment are virally suppressed. The government has pledged to end new HIV cases by 2030 and today on World AIDS Day, England launches its first ever HIV Commission (see press report attached), which has released 20 clear recommendations to meet this life-changing target that will see no new cases past 2030.

 

Lewisham  

However, continued effort is still required as Lewisham continues to have one of “the highest rates of HIV in Europe3   exceeding NICE threshold for “extremely high prevalence” at 8 per 1000 4.

In Lewisham the majority of new HIV diagnoses reported in the SIB were through heterosexual contact , in those aged >35y.

We know HIV disproportionally affects minority groups, and in South London 72% of the patients identified were from Black and Minority ethnic groups (see graph), who also continue to be more likely to be diagnosed late.  This highlights the importance in offering HIV tests to diagnose HIV earlier, when outcomes are improved, reduce onwards transmission & stigma by promoting U=U (Undetectable = Untransmissible) and reduce the health inequalities.

 

How do GPs know who to test?

NICE5advises HIV testing should be offered in primary care:·         To people newly registering at a practice or having a blood test if they have not had an HIV test in the past 12 months, in areas where the prevalence of diagnosed HIV is greater than 2 in 1000: Lewisham is 8 in 1000

·         To people presenting with symptoms longstanding HIV infection or indicator diseases 6(see Appendix 1 below)

·         If the person requests a test, has a risk factor for HIV, or has another sexually transmitted infection.

·         As part of routine antenatal care.

 

The practical reasons Lewisham GPs offer an HIV test:

·         They are routinely offered to all patients in Lewisham who have not had HIV test with their GP in the past year (reduce stigma)

·         Successful HIV treatment means people with HIV can live as long as anyone else 7.

·         If someone with HIV is taking effective HIV treatment and has an undetectable viral load they cannot pass on HIV. U=U Undetectable = Untransmissible (It can take up to six months on treatment for some people to become undetectable)7.

 

  • PrEP (Pre-exposure prophylaxis) will be available at Lewisham Sexual Health Services from the 1st of December. Individuals interested in accessing PrEP can contact the clinic on 0203 049 3500. HIV Consultant Dr Mabonga will be providing teaching on PrEP on the 9th of December for the Lewisham CEPN Hub ‘Lunch and Learn’ series. Click here for more information.

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Appendix 1

Conditions where prevalence of undiagnosed HIV is more than 0.1%= cost effective

·         Community-acquired pneumonia *

·         Unexplained lymphadenopathy *

·         Mononucleosis-like illness *

·         Sexually transmitted infections *

·         Seborrheic dermatitis/exanthem

·         Herpes zoster

·         Unexplained leukocytopenia/thrombocytopenia lasting more than 4 weeks

·         Malignant lymphoma

·         Hepatitis B or C (acute or chronic)

*Note in review of GP records for the 22 new HIV diagnosis, Lewisham patients had presented to their GP’s in the 2 years preceding their diagnosis with these conditions or been treated by GPs for Chlamydia or Trichomonas without being offered an HIV test.

Conditions likely to have an undiagnosed prevalence of HIV of more than 0.1%

·         Subcortical dementia

·         Peripheral neuropathy

·         Unexplained weight loss

·         Unexplained chronic diarrhoea

 

Potentially AIDS-defining conditions

Bacterial infections

·         Mycobacterium tuberculosis, pulmonary or extrapulmonary

·         Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary

·         Mycobacterium, other species or unidentified species, disseminated or extrapulmonary

·         Pneumonia, recurrent (2 or more episodes in 12 months)

·         Salmonella septicaemia, recurrent

Viral infections

·         Cytomegalovirus retinitis

·         Cytomegalovirus, other (except liver, spleen, glands)

·         Herpes simplex, ulcer(s) for more than 1 month/bronchitis/pneumonitis

·         Progressive multifocal leucoencephalopathy

Parasitic infections

·         Cerebral toxoplasmosis

·         Cryptosporidiosis diarrhoea for more than 1 month

·         Isosporiasis for more than 1 month

·         Atypical disseminated leishmaniasis

·         Reactivation of American trypanosomiasis (meningoencephalitis or myocarditis)

Fungal infections

·         Pneumocystis carinii pneumonia

·         Candidiasis, oesophageal

·         Candidiasis, bronchial/tracheal/lungs

·         Cryptococcosis, extrapulmonary

·         Histoplasmosis, disseminated/extrapulmonary

·         Coccidiodomycosis, disseminated/extrapulmonary

·         Penicilliosis, disseminated

Neoplasms

·         Cervical cancer

·         Non-Hodgkin’s lymphoma

·         Kaposi’s sarcoma