Kicking the habit – how can we improve the routine care for patients who are well controlled living with HIV?

Abstract

The objective is to improve and standardise HIV care for people with well-controlled HIV across the region by comparing monitoring within services to UK audit standards. This was a retrospective case note review from 01.01.2018 to 31.12.2018. The standards were sourced from the British HIV Association (BHIVA), the British Association for Sexual Health and HIV (BASHH), and the Faculty of Sexual and Reproductive Health (FSRH). Six services took part with 228 patient records being audited. Two of the 5 national standards were met (blood pressure and medication review). From the 8 areas previously audited in 2014, 6 showed improvements (offer of STI screen, medication review, urinalysis, mental health screen and influenza vaccination documentation). Cardiovascular disease (CVD) risk and transmission risk had poorer documented outcomes. In addition, nearly one-third of patients were over-tested regarding their CD4 count. We recommend that letters should include a standard message about U = U (undetectable = untransmittable) and vaccinations; CVD risk and FRAX should be calculated once a year in place of a routine letter; an annual summary letter should be written in place of a letter after each clinic visit; and consistent use of a proforma, with BHIVA/BASHH/FSRH recommendations on monitoring included.

Keywords

HIV HIV care guidelines monitoring people living with HIV

Introduction

There is a vast amount of medical evidence supporting a wide range of routine investigations and monitoring required in HIV care. Some of these are recommended every visit, and are unlikely to be missed, whereas others are required 1- to 3-yearly.¹ Overscreening can lead to patient fatigue in attendance, overrunning of clinics and unnecessary investigation costs. Omitting screening may result in missed opportunities to prevent medical complications, and therefore, unnecessary morbidity and mortality.²

An initial regional audit was undertaken in 2014 showing a wide variation between services for some parameters.³ Services that used a proforma had higher compliance with national investigation and monitoring standards/recommendations. For investigations that were recommended every 2 to 3 years by the British HIV Association (BHIVA), those services adopting an annual check, rather than every 2 or 3 years were more compliant. It was therefore recommended at a regional level that proformas would be shared between services, and annual checks would replace those required every 2–3 years.

A total of 1920 people accessed HIV care in North East England in 2018 across 8 HIV services, in 12 local authorities. All services had medical-led clinics, with one offering a specialist nurse-led clinic. The North East and Cumbria HIV clinical network meets quarterly with an annual update meeting where regional audits are presented.

Methods

In the initial 2014 audit, large amounts of data were collected, and on reflection it was felt that the number of areas in the re-audit should be reduced. These were chosen for those where performance could be improved, they were of clinical relevance and took over-testing (and potential cost saving) into consideration.

The 2019 audit was a retrospective case note review from 01.01.2018 to 31.12.2018. Patients attending the service for HIV-related care in 2018 who had a viral load below 200 copies/ml across the study period were included. Persons who would normally receive their HIV care from another HIV service, those who did not attend for care at the auditing service in 2018, and those that were diagnosed in 2018 were excluded from the data collection. The first 50 attendees (or number of HIV patients meeting criteria in clinics with less than 50) for HIV-related care from 1st January 2018 were assessed. National audit standards were sourced from BHIVA, the British Association for Sexual Health and HIV (BASHH), and the Faculty of Sexual and Reproductive Health (FSRH).

The audit standards were as follows:

Cardiovascular disease (CVD) risk assessed within first year then 3-yearly in those aged over 40 years, target 90% (changed to within last 1 year for audit purpose after the recommendations made following the 2014 audit).¹

Blood pressure (BP) recorded in last 2 years, target 95% (changed to within last 1 year for audit purpose, after the recommendations made following the 2014 audit).¹

People with sustained viral suppression (at least 6 months) and high adherence to ART should have documented evidence that they have been advised that they cannot transmit HIV to their sexual partners, target 90%.⁴

Mental health screening in last 12 months, target 90%.⁴

Proportion of all patients having documented medication review in last 15 months (changed to within last 1 year for audit purposes) target 97%.¹

Other areas audited without national auditable outcome standards:

Urinalysis performed in last 12 months.¹

CD4 count requested (CD4 count testing performed in those with CD4 <200 cells/µL every 3 to 6 months, with a CD4 count of 200–350 cells/µL annually, and no testing for those with a CD4 count >350 cells/µL for >12 months).¹

Proportion that have been offered testing for sexually transmitted infections (STIs) in the last 12 months. National guidelines recommend an annual screen if partner change, or 3-monthly in those at high risk.⁵

Offered an annual influenza vaccine, or recommendation to the GP to provide the vaccine in last 12 months.⁶

Lipid profile done in last 12 months in those over 40 years old¹ (not in original audit).

FRAX score documented in last 1 year¹ (not in original audit, changed from every 3 years in national guideline, following the recommendations made after the 2014 audit).

Results

Six services took part with a total of 228 patient records being audited. Table 1 compares all patients accessing HIV care in 2018 per service, and shows the variable age-range within each service. No other demographics were recorded, as age was the only characteristic that would influence whether data should have been captured.

Table 1.

Number of patients included in the audit per participating clinic; age range of all patients in service included to show adequate representation in audit.

Clinic	Age range of total patients in service			Number of patients in audit
Clinic	<40 yrs	40–49yrs	≥50 yrs	Total	<40 yrs	40–49 yrs	≥50 yrs
1	44%	17%	39%	18	8 (44%)	3 (17%)	7 (39%)
2	40%	17%	43%	30	9 (30%)	7 (23%)	14 (47%)
3	34%	27%	39%	40	14 (35%)	15 (37%)	11 (28%)
4	25%	34%	41%	40	6 (15%)	13 (32%)	21 (53%)
5	41%	24%	35%	50	7 (14%)	17 (34%)	26 (52%)
6	44%	23%	33%	50	22 (44%)	16 (32%)	12 (24%)
				Total: 228	66	71	91

Table 2 shows results compared to both the initial 2014 audit, and the national auditable standards. Table 3 shows the results of those areas where there are no national auditable outcomes. Data were absent for 2 patients for CD4 testing.

Table 2.

Audit results with comparison to national auditable standards and the initial 2014 audit.

	UK national standard	2014 mean	2019 mean	Good practice
CVD risk^a	90%	75%	69% (112/162)	1 clinic met standard
BP	95%	82%	95% (217/228)	4 clinics met standard
Transmission discussion	90%	58%	37% (85/228)	0 clinics met standard
Mental health screen	90%	40%	75% (172/228)	4 clinics met standard
Medication review	97%	75%	99.6% (227/228)	ALL clinics met standard

^ain those >40yrs old.

Table 3.

Results of 2019 audit compared with initial 2014 audit (if applicable), where these are recommended but there are no national auditable standards.

	2014 mean	2019 mean	Good practice
Urinalysis	67%	89% (203/228)	2 clinics over 90%
Appropriate CD4 count^a	n/a	69% (156/226)	2 clinics over 90%
STI screen offer	52%	62% (141/228)	2 clinics over 70%
Influenza vaccine discussion	52%	80% (183/228)	3 clinics over 90%
Lipid profile^b	n/a	96% (156/162)	5 clinics over 95%
FRAX score^c	n/a	34% (31/91)	1 clinic over 70%

^aCD4 count testing performed in those with CD4 <200 cells/µL every 3–6 months, with a CD4 count of 200–350 cells/µL annually, and no testing for those with a CD4 count >350 cells/µL for >12 months.

^bin those aged >40yrs.

^cin those aged >50yrs.

Overall 62% (141/228) of all patients were offered an STI screen, which increased to 93% if they met the screening criteria (partner change in last year); 75% (172/228) of patients were screened for mental health problems with 20% of those having a mental health issue identified requiring further action.

Results of over testing:

83% (55/66) of those under the age of 40 had lipids performed.

A small number (4%) had FRAX screen performed under the age of 50.

69% of patients had their CD4 count checked appropriately and 30% were over-tested. Over-testing occurred most commonly in the 200–350 cells/µL range, where 74% (17/23) of patients had two or more CD4 counts done; 24% (46/188) of patients with a CD4 count of >350 copies/mL for 12 months or more were still having CD4 counts done.

Discussion

Only 2 of the 5 national standards were met (BP and medication review). From the 8 areas previously audited in 2014, 6 showed improvements (offer of STI screen, medication review, urinalysis, mental health screen and influenza vaccination documentation). CVD risk and transmission risk had poorer documented outcomes. In addition, in terms of over-testing there is obviously a cost-saving benefit to monitoring CD4 counts appropriately; nearly a third of patients were being over-tested.

The prevalence of mental health issues is substantially higher among people living with HIV compared to the general population.^7–9 The literature reports up to 23% of those living with HIV as having mental health issues, similar to our audit findings, compared with 0.3%–0.4% in the general population.⁸ Recent North East England data have shown our region has the highest male suicide rates in the United Kingdom (20.4 per 100,000)¹⁰ and that 16% of the local population have a mental health diagnosis.¹¹ Although there was improvement compared with the results from our initial audit in mental health screening, it is essential we meet the national standard. Using self-completed patient validated tools such as the Patient Health Questionnaire-9 (PHQ-9)¹² could aid discussion and make consultation time more efficient.

Regarding STI screening, there were missed opportunities for STI screening. With the introduction of pre-exposure prophylaxis (PrEP), there is the potential for an increase in other STIs.¹³ Making STI screening an annual requirement (as a minimum) may prevent STIs being undiagnosed.

Although data were anonymised between services, it was agreed that the auditors could approach those services that were performing well to see how they were running their clinics and potentially share best practice. The common themes amongst those services that were performing better than others were the use of proformas every 6 months, or having an ‘annual review’ using one proforma; and adding standardised advice to letters sent to the patient/GP regarding transmission risk and influenza vaccination. The presence of dedicated nurses/HCAs assigned to HIV clinics was also found to be beneficial.

With the development of electronic records for patients, innovative ways to improve our repeated poor performance could be developed. A standardised annual review proforma could be embedded in a range of IT systems or used as a standalone form which could then be printed that captures all of the information recommended.

In our region we have recommended the following changes as audit outcomes;

All letters to include a standard message about U = U (undetectable = untransmittable) and vaccination requirements.

Rather than a letter after each clinical visit, one annual summary letter should be written. This allows time to document an accurate CVD risk and FRAX score based on recent results. Consistent use of a proforma to aid clinical care, with BHIVA recommendations on monitoring included, either as an annual review or split across two clinic attendances so that all aspects are covered within each 12-month period for implementation across the region.

Conclusion

Current UK recommendations for annual investigations and monitoring are numerous.^1,4–6 Patients receiving long term HIV care in the UK have risen in the last decade¹⁴ whilst most clinical services have not seen an increase in funding or staff and in fact have been required to make cost savings.¹⁵ We also have an ageing population of people living with HIV with additional increasing co-morbidity.¹⁶ Discussion in our HIV clinical network around the audit findings included time pressures on clinics and how practically to cover all areas to benefit patient care required in the limited time available. National recommendations for HIV monitoring should include pragmatic and practical solutions on how they can be implemented.

There are some limitations of this audit to consider. Firstly, this is an audit of documentation, so it can be difficult to make definitive conclusions if the documentation is poor. Secondly, no clinical information was taken into account, patients may have had CD4 count investigations or lipids performed for other clinical reasons other than as part of routine HIV care. Finally, only 6 of the 8 clinics in the region participated in the audit.

Footnotes

Acknowledgements

Our thanks to the following for people for participating in data collection for this regional audit; Allan Harrison, Conrad White, Alison Wardropper, Vivienne Wholey, Sue Ralph, David Chadwick, Stephen Bushby, Oluseyi Hotonu, Sarah Duncan.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article

ORCID iD

M Dresser

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