Eileen Nixon

Will I? Won't I? why do men who have sex with men present for post-exposure prophylaxis for sexual exposures?

Background: Failures of post-exposure prophylaxis following sexual exposure (PEPSE) to prevent seroconversion have been reported and are often associated with ongoing risk exposure. Understanding why men who have sex with men (MSM) access PEPSE on some occasions and not others may lead to more effective health promotion and disease prevention strategies Methods: A qualitative study design using semi-structured interviews of 15 MSM within 6 months of them initiating PEPSE treatment at an HIV outpatient service in Brighton, UK. Results: PEPSE seeking was motivated by a number of factors: an episode that related to a particular sexual partner and their behaviour; the characteristics of the venue where the risk occurred; the respondent’s state of mind and influences of alcohol and recreational drug use; and their perceived beliefs on the effectiveness of PEPSE. Help was sought in the light of a “one-off” or “unusual” event. Many respondents felt they were less likely to behave in a risky manner following PEPSE. Conclusion: If PEPSE is to be effective as a public health measure, at risk individuals need to be empowered to make improved risk calculations from an increased perception that they could be exposed to HIV if they continue their current behaviour patterns. The concern is that PEPSE was sought by a low number of MSM implying that a greater number are not using the service based on failure to make accurate risk calculations or recognise high-risk scenarios.

A discrete choice experiment to assess people living with HIV's (PLWHIV's) preferences for GP or HIV clinic appointments

Objectives To understand which aspects of general practitioner (GP) and HIV clinic appointments people living with HIV (PLWHIV) most value when seeking advice for new health problems. Methods A discrete choice experiment using a convenience sample of people diagnosed with HIV. Participants were recruited from 14 general HIV clinics in the South East of England between December 2014 and April 2015. ORs were calculated using conditional logit (CLOGIT) and latent class models (LCMs). Results A total of 1106 questionnaires were returned. Most participants were male (85%), white (74%) and were men who have sex with men (69%). The CLOGIT analysis showed people particularly valued shorter appointment waiting times (ORs between 1.52 and 3.62, p<0.001 in all instances). The LCM analysis showed there were two distinct classes, with 59% and 41% of respondents likely to be in each. The first class generally preferred GP to HIV clinic appointments and particularly valued ‘being seen quickly’. For example, they had strong preferences for shorter appointment waiting times and longer GP opening hours. People in the second class also valued shorter waiting times, but they had a strong general preference for HIV clinic rather than GP appointments. Conclusions PLWHIV value many aspects of care for new health problems, particularly short appointment waiting times. However, they appear split in their general willingness to engage with GPs.

Patients' perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study.

The objective of this study was to identify the aspects of healthcare that are most valued by people with HIV and to describe their concerns and preferences for the future delivery of services for non-HIV-related illness. Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, gender, sexual orientation and ethnicity. Data were analysed using Framework Analysis. The results showed that among the 74 respondents (61% male), a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners to manage patient confidentiality or deal appropriately with the emotional and social challenges of living with HIV. Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services and increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV.

What is the extent of repeat prescriptions for post-exposure prophylaxis for HIV after sexual exposure among men who have sex with men in the UK?

People who repeatedly present for post-exposure prophylaxis (PEP) for prevention of HIV following a high-risk sexual exposure are of concern according to the British HIV Association PEP guidelines. The aim of this audit was to determine the extent of repeat PEP prescriptions for men who have sex with men (MSM) by conducting a retrospective review of patient notes from a 5-year period at one genitourinary medicine clinic. Over the 5 years, 107 of 929 MSM (11.5%; 95% confidence interval: 9.45-13.55) received more than one PEP prescription (repeat range 1-8; mean=3.3, s.d.=1.44). Forty percent of these had received three or more PEP prescriptions. Seven of the 107 became HIV positive. Patients need to be offered and encouraged to take up behavioural risk reduction interventions at the time of each PEP prescription.

Which aspects of health care are most valued by people living with HIV in high-income countries? A systematic review

BackgroundIncreasing numbers of people with HIV are living into older age and experiencing comorbidities. The development of new models of care to meet the needs of this population is now a priority. It is important that the views and preferences of patients inform the development of services in order to maintain high levels of patient satisfaction and engagement. The aim of this systematic review was to determine which aspects of healthcare are particularly valued by people living with HIV.MethodsWe searched electronic databases and reference lists of relevant articles. The search strategy was developed to identify articles reporting on HIV positive patients’ perceptions, evaluations or experiences of healthcare services and factors associated with satisfaction with care. Peer-reviewed papers and conference abstracts were included if the study reported on aspects of health care that were valued by people living with HIV, data were collected during the era of combination therapy (from 1996 onwards), and the paper was published in English. A thematic approach to data synthesis was used.ResultsTwenty-three studies met the inclusion criteria. Studies used both qualitative and quantitative methods. Six studies specifically reported on relative importance to patients of different aspects of care. The valued aspects of care identified were grouped into seven themes. These highlighted the importance to patients of: a good health care professional-patient relationship, HIV specialist knowledge, continuity of care, ease of access to services, access to high quality information and support, effective co-ordination between HIV specialists and other healthcare professionals, and involvement in decisions about treatment and care. We were unable to determine the relative importance to patients of different aspects of care because of methodological differences between the studies.ConclusionsThis review identified several attributes of healthcare that are valued by people living with HIV, many of which would be relevant to any future reconfiguration of services to meet the needs of an ageing population. Further research is required to determine the relative importance to patients of different aspects of care.

UG3 Connect email – 8 years’ experience of an email clinic in an hiv outpatient setting

Introduction With advances in HIV therapy, many people are living longer healthier lives. Simultaneously our cohorts are ageing with 42% of individuals locally aged over 50. Our service looked for innovative ways of reducing visits for stable patients while increasing capacity to manage complex patients. In 2008 we introduced an email service whereby patients are seen once a year with interim results checked and emailed to them. We report on a review of the Connect email service. Methods Individuals who had ever registered with the email service and their current status were identified from our prospective clinical database. Reasons for ‘exiting’ or ‘pausing’ the service were identified by a case notes review. A service evaluation was carried out via staff and patient surveys. Results Since October 2008, 888 individuals have registered with our email service: 89.8% male (n=797); median age 48 (range 22–84). At the time of review (Oct 2016) 550 (550/2370 = 23% of total cohort) were under active email follow-up. In eight years, 171 (19.3%) have ‘exited’ the email service - reasons included: co-morbidities (46.2%); ARV switch/start (18.7%); patient choice (12.9%) and non-attendance/adherence (11.1%). A further 167(18.8%) has been ‘paused’, mainly due to co-morbidities (58.1%); ARV switch/start (20.4%) and research (16.2%). Non-attendance/adherence was more common in younger patients while co-morbidities predominated among older patients (aged >50). In the staff survey, barriers for enrolling patients on Connect included ‘difficulty letting go’ of regular appointments, email access and confidentiality concerns. Discussion As the email service is an integral part of HIV care in our unit, understanding why patients leave Connect and barriers to enrolment will enable continued effectiveness of the service.

The management of comorbidities in older people living with HIV in England: a cross sectional survey.

The success of combination antiretroviral therapy has contributed to a rapid rise in the number of people living with HIV (PLWH) who are aged ≥ 50 years [1]. As a result, comorbid conditions associated with ageing, including heart, bone, liver and kidney disease and cognitive impairment, are now common [2,3] and have led to an increase in polypharmacy [4]. Managing comorbid conditions in PLWH is now a clinical priority. Current HIV services were designed to focus on the management of HIV infection and may not meet the needs of this ageing population. We conducted an online survey to investigate how HIV services are currently managing comorbidities in PLWH. A link was sent to one consultant in every HIV outpatient unit in England via the British HIV Association (BHIVA) audit committee. The survey asked about types of services available at the clinic for patients with comorbidities, including primary care services, and care coordination and management. Responses were received from a consultant at 44 units. In total, 12 (27%) clinics provided one or more services (Table 1). Those providing specialist services varied in cohort size from 100 to > 2000. The most commonly reported service was a specialist clinic for the management of a noninfectious comorbidity in addition to HIV infection (Table 1). Most frequently these were renal, gastroenterology, oncology, neurology or dermatology clinics. This type of service was most often a joint clinic delivered by an HIV and non-HIV clinician together, in a combination of virtual and inperson appointments. Dedicated services for older PLWH were also reported (n = 5; 11%). Eligibility for this type of service was determined by age (≥ 50 years) or the presence of a comorbidity. Two (5%) units reported specialist services for HIV-infected patients with multiple comorbidities. Nurse-led clinics for the management of patients with comorbid conditions were also reported (n = 6; 14%). Two (5%) HIV units had a general practitioner (GP) on site. A further two (5%) reported having access to a locally enhanced service providing enhanced primary care for HIV-positive patients. The majority of units (n = 36; 82%) provided care coordination, most commonly delivered by an HIV specialist doctor (n = 27), a GP (n = 18), an HIV specialist nurse (n = 11) or the patient themselves (n = 9). Case management for patients with multiple comorbidities was provided by 11 (25%) units. This was usually delivered by an HIV specialist nurse (n = 6) or HIV specialist doctor (n = 5). Self-management support, provided by 18 (41%) units, was usually nurse-led or delivered as part of an expert patient programme (n = 11; 61%). This survey shows the variety of service models used in clinics throughout England for the management of HIV-infected patients with comorbidities. However, only 27% of clinics surveyed reported any type of service for the management of comorbidities and only 5% reported dedicated services for the management of multiple comorbidities. Currently there is a lack of research to determine how different service models impact on clinical and patient-reported outcomes. Given the increasing burden of comorbidities in this population, developing services to meet the needs of an ageing HIV-infected population is a priority. Correspondence: Elaney Youssef, Brighton and Sussex Medical School, Room 318b, Mayfield House, University of Brighton, Falmer, Brighton BN1 9PH, UK. Tel: 01273 644526; e-mail: e.k.youssef@bsms.ac.uk Table 1 Reported services for patients with comorbid conditions