A new report from the British HIV Association (BHIVA) suggesting innovative ways of working for healthcare professionals who care for people living with, or at risk of, HIV was launched today in London. Standards for HIV Clinical Care includes a wide range of recommendations that BHIVA hopes will reduce late, missed or mistaken HIV diagnoses as well as inappropriate treatment. These include moving towards routine ‘opt out’ HIV testing in primary care settings, and more sharing of information within newly set-up managed clinical networks.
This report comes at a time of widespread uncertainty within the National Health Service (NHS), and represents the outcome of a project which was initiated by BHIVA, and following a process of – often difficult – consultation and discussion has been fully endorsed by the Royal College of Physicians (RCP), the British Association for Sexual Health and HIV (BASHH) and the British Infection Society (BIS).
“BHIVA took a risk” initiating these standards, commented BASHH President Simon Barton at the launch event. He noted that they required unprecedented cooperation between different professional organisations, which “put aside professional or territorial issues in order to achieve the best patient care. It’s a new way of working, and it’s absolutely vital we have a reactive and better way of working together in the future.”
The report's recommendations are designed to reflect the level of care expected to be achieved throughout the NHS. The document broadly outlines who should provide HIV testing; who should provide treatment of HIV- and non-HIV-related issues; and how services should be organised. It also addresses initial and ongoing training of HIV clinicians, nurses and pharmacists.
New era of networks and information sharing
It recommends that in order to achieve national standards – and to avoid postcode lottery-type situations – new managed clinical networks each covering a defined geographical area and group of NHS organisations should be set up, each comprising two types of clinical services:
- HIV units providing outpatient care for the majority of patients with uncomplicated HIV infection.
- Single-site or virtual/cluster HIV centre within each network providing services for patients with more specialised needs, including complex outpatient care, inpatient care and referral/advice services.
In order for these networks to succeed, however, patient records will need to be shared more widely and the document notes that “HIV care records should reflect the same access protocols as for other chronic diseases. While respecting the right of individual patients to opt out from record sharing, information relating to HIV treatment and care should be recorded in ordinary NHS records.”
The document shares some concerns over confidentiality in the era of electronic patient records – noting that HIV remains a stigmatised condition – although it states that “it should not be assumed that electronic information storage and communication are inherently less secure than more traditional methods. Consequently, it recommends that “the right of individual patients to opt out of record sharing or to place this information in a sealed [electronic] envelope should be respected, but clinicians should not encourage this practice.” However, British Infection Society President, Nick Beeching, remarked that “patients need to be confident that records will be secure as they go electronic.”
More opportunities to test for HIV recommended
Past BHIVA audits have noted that late diagnosis is a major cause of illness and death for people with HIV in the UK, and several studies have suggested that in some cases diagnoses are being missed in GP practices, as well as in acute and inpatient care services in hospitals primarily due to a perceived barrier in being able to offer HIV antibody testing.
Consequently, moving further than last year’s recommendations from BASHH – which recommended opt-out HIV testing in sexual health clinics – BHIVA now recommends that “all general practices and acute medicine services should provide diagnostic HIV testing, and such testing should routinely be considered for patients coming in contact with secondary care.”
BHIVA’s Chair Margaret Johnson comments: “One big change we want to see is much more widespread HIV testing to facilitate planned care, so that fewer people remain undiagnosed until they develop a major HIV-related illness.”
Professor Johnson added that these standards “give a strong message to the Department of Health” and will “make sure people can receive routine HIV care locally and conveniently, but can also access more specialised care for complex problems.”
The standards document is available from BHIVA.