People living with HIV in the UK not receiving appropriate monitoring of heart disease risk

The majority of HIV-positive people in the UK are not receiving recommended monitoring of cardiovascular risk, according to the results of an audit conducted by the British HIV Association (BHIVA) published in BMC Infectious Diseases.

The audit also showed that only a small minority of people are receiving appropriate monitoring of bone mineral density and fracture risk. There was wide variation between clinics in monitoring rates for some conditions. But the survey also revealed some excellent practice, with monitoring of viral load and adherence to antiretrovirals exceeding national targets.  

“There was high participation in the national audit and the data showed good practice in some areas,” comment the authors. “However, low recorded rates of monitoring of cardiovascular risk were noted and smoking status was not reported for one in seven patients, and less than half of current smokers were offered cessation support.”

Glossary

cardiovascular

Relating to the heart and blood vessels.

bone mineral density (BMD)

The higher your bone mineral content, the denser your bones are. And the denser your bones, the stronger they are and the less likely they are to break. A bone density test uses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones that are most commonly tested are in the spine, hip and sometimes the forearm. 

syphilis

A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

resistance testing

Laboratory testing to determine if an individual’s HIV strain is resistant to anti-HIV drugs. 

cervix

The cervix is the neck of the womb, a tight ‘collar’ of tissue that closes off the womb except during childbirth. Cancerous changes are most likely in the transformation zone where the vaginal epithelium (lining) and the lining of the womb meet.

Improvements in treatment and care means that HIV is now a chronic, manageable condition with many HIV-positive people having a normal or near-normal life expectancy.

Cardiovascular, liver, kidney and bone disease are now important causes of illness in HIV-positive individuals. The prompt identification of these conditions is important so that appropriate therapy can be initiated.

In 2011, BHIVA issued national guidelines for the routine monitoring of HIV-positive adults. Adherence to these guidelines was audited in 2015.

All clinics offering care to HIV-positive adults were invited to complete a case-note review and a brief survey of local clinical practices. They were also asked to randomly select 50 to 100 of their patients who attended care in 2014 and/or 2015. Each clinic was asked to provide demographic details for these patients and whether results of 22 standard monitoring outcomes had been recorded.

A total of 123 clinics participated and provided data on 8258 patients, approximately 10% of HIV-positive patients in clinical care.

The majority of these people (90%) were on (antiretroviral therapy) ART, and of these 90% had a viral load measurement within the past six months, exceeding the guideline target of 80%. Adherence to therapy was assessed in 93% of individuals, once again exceeding the target (70%) set by the guidelines. But only 89% of individuals had all their medications recorded within the previous year, despite a 100% target.

Monitoring of viral hepatitis should be an important part of HIV care. Sixty-one per cent of patients were hepatitis A vaccinated, immune or seropositive. The majority of patients (82%) had their hepatitis B serology fully reported. Hepatitis C antibody status was negative for 91% of patients, positive for 5% and unknown/unanswered for 3.4%. Two-thirds of the negative patients had been tested in the previous year, including 74% of men who have sex with men (MSM) and 62% of people who inject drugs. Hepatitis C RNA testing had been performed for 91% of HCV-positive individuals.

Only 45% of patients on ART had a documented ten-year cardiovascular disease (CVD) risk assessment within the previous three years. The monitoring rate was just 32% for individuals not on ART. Both rates were well below the 70% target set in the guidelines. Approximately half (48%) of patients aged 50 and above and receiving ART had been assessed for CVD risk within the past three years. Smoking status was documented for two-thirds of patients, falling well short of the 90% target. Only 45% of smokers had been offered cessation support.

Two-thirds of patients were offered an annual sexual health screen, including 72% of MSM and 61% of heterosexuals. Syphilis screening was documented for 63% of patients, including three-quarters of MSM and 55% of heterosexuals. Just over half of women (53%) had an annual cervical cytology screen with a further 22% advised to seek this test at a GP or sexual health clinic.

Fracture risk was assessed within the previous years in only 17% of patients aged over 50. Bone mineral density was measured in just 17% of ART-treated patients aged 70 and above.

“The growing population of older patients living with HIV were…overlooked in terms of bone health, with very low rates of fracture risk assessment and bone mineral density recording,” write the researchers. “It is not clear if low recorded rates of monitoring of bone density was due to lack of availability of bone densitometry measurement.”

Resistance testing varied between sites, but only 27% of clinics met the target of having a resistance test or stored sample for 90% of patients. Rates of blood pressure monitoring and liver and kidney function testing were high at between 86 and 97%.

A fifth of patients were given an annual flu vaccination, with 36% given advice on other services where this could be obtained.

“There may be a perception that primary care is responsible for certain monitoring and services such as cardiovascular risk and providing most vaccinations,” conclude the authors. “Hence greater clarity in these areas, particularly in what the forthcoming tariffs for HIV care cover, will help clinics focus on areas they are responsible for. Improved communication between HIV and primary care services would streamline and improve care.” The investigators also stress the need for clinics to develop strategies to improve the care of older HIV-positive patients.

References

Molloy A et al. Routine monitoring and assessment of adults living with HIV: results of the British HIV Association (BHIVA) national audit 2015. BMC Infectious diseases, 17: 619. DOI 10.1186/s12879-017-2708-y (2017).