Nadia Ahmed

British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015

Writing Group Duncan Churchill, Chair, Royal Sussex County Hospital, Brighton, UK Laura Waters, Vice Chair, Mortimer Market Centre, London, UK Nadia Ahmed, Mortimer Market Centre, London, UK Brian Angus, University of Oxford, UK Marta Boffito, Chelsea and Westminster Hospital, London, UK Mark Bower, Chelsea and Westminster Hospital, London, UK David Dunn, University College London, UK Simon Edwards, Central and North West London NHS Foundation Trust, UK Carol Emerson, Royal Victoria Hospital, Belfast, UK Sarah Fidler, Imperial College School of Medicine at St Mary’s, London, UK †Martin Fisher, Royal Sussex County Hospital, Brighton, UK Rob Horne, University College London, UK Saye Khoo, University of Liverpool, UK Clifford Leen, Western General Hospital, Edinburgh, UK Nicola Mackie, Imperial College Healthcare NHS Trust, London, UK Neal Marshall, Royal Free Hospital NHS Trust, London, UK Fernando Monteiro, UK-CAB Mark Nelson, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK

Remission of human immunodeficiency virus-related lymphoma in association with immune reconstitution on anti-retroviral therapy, without chemotherapy.

In the developed world, the incidence of human immunodeficiency virus (HIV)-related non-Hodgkin lymphoma (NHL) has significantly declined since the introduction of effective anti-retroviral therapy (ART).[1,2] Patients developing lymphoma while on ART have significantly improved outcomes, comparable with those for lymphoma in non-HIV populations.[3] Commencement of anti-retroviral drugs is essential for successful lymphoma management in treatment naı̈ve individuals found to be HIV positive at diagnosis.[4] Cytotoxic chemotherapy in HIV positive patients causes a fall in CD4 count of 50%, rendering them at increased risk of opportunistic infection and may slow the immune re-constitution seen with ART.[5] While inducing profound cell mediated immunodeficiency, HIV infection also leads to immune activation and a chronic inflammatory state which, along with Epstein Barr virus (EBV) and other infective etiologies, may contribute to the pathogenesis of lymphoma. Immunologically, there are parallels with other immunodeficiency states in which lymphoma may arise, such as post-solid organ or stem cell transplant and inherited immunodeficiency. EBV plays a significant role in lymphomagenesis, whatever the underlying nature of immune deficiency.[6,7] Primary management of the EBV driven post-transplant lymphoproliferative disorders (PTLD) involve attempts at restoring immune function. CD4 and CD8 positive T cells are essential for controlling primary and reactivated EBV, thus PTLD is treated either by reduction of immunosuppression, immunotherapy with anti-CD20 antibody which targets the EBV containing lymphocytes or the administration of specific cytotoxic T lymphocytes.[8] ART has its effects by reducing HIV replication, restoring T-cell numbers and function along with cellular and humoral immune responses. However, it is sometimes associated with significant toxicity, especially when patients have acquired immune deficiency syndrome (AIDS) defining infections, where potentially life threatening immune reconstitution disease or immune reconstitution inflammatory syndrome may be activated, unmasking opportunistic infection or malignancy.[9,10] It is therefore possible that severely immunosuppressed patients with detection of HIV infection at the time of diagnosis of lymphoma could respond to immune reconstitution without the need for conventional chemotherapy regimens, in a similar manner to patients with PTLD. In this retrospective UK wide case series, we report the successful management of nine patients with different lymphoma subtypes treated with ART alone. Selected lymphoma specialists throughout UK were contacted via email to report patients diagnosed with lymphoma who had responded to ART alone. Centers were asked to provide anonymized information including demographics, histological subtype, stage, HIV viral load, CD4 count, antiretroviral regimen, progression and clinical outcomes. Central pathology review was not possible, however, all the patients were managed in centers with lymphoma and HIV expertise and in keeping with Improving Outcome Guidance had been discussed in multidisciplinary meetings with lymphoma and HIV specialists. Tissue specimens were assessed by histopathologists with special expertise in the diagnostics of lymphoma.

Home delivery of medication - the role of a patient information leaflet on maximising service uptake.

There are currently over 30,000 HIV-positive individuals in London and over 25,000 on anti-retroviral therapy. In 2009/2010, this equated to £170m spent by London’s NHS on anti-retroviral drugs. Ways employed to reduce this cost include standardising the drugs patients are on and delivering medication to patients at home. Home delivery (HD) medication is exempt from value-added tax. The savings made from 10 patients using the home delivery service would free up resources to provide anti-retroviral therapy to one further patient. Studies have shown that concerns surrounding potential breaches of confidentiality are a potential barrier to some people using the home delivery service. In order to challenge these concerns, a leaflet was devised highlighting the major benefits to both the patient and the NHS of home delivery and addressing concerns over confidentiality. The leaflet was handed out to patients at the Mortimer Market Centre who were currently on anti-retroviral medication but not on home delivery. They were asked to complete a survey on their views of the service before and after reading the leaflet, whether they had been previously aware of the service and whether their concerns had been addressed. Some 79% felt that the patient information leaflet addressed all of their concerns, and it helped 11% decide whether to consider using home delivery. However, as more patients were opposed to the service after reading the patient information leaflet than those considering it, more work needs to be done to explore patients’ concerns and other factors influencing home delivery service uptake.

What impact has tendering had on trainees? Results of a national survey by British Association for Sexual Health and HIV Trainees’ Collaborative for audit, research and quality improvement projects:

In April 2013, local authorities gained responsibility for commissioning sexual health services in England. With many services going out to tender and resultant change in services or service provider, there is anecdotal evidence that this has impacted on the education, training and morale of genitourinary medicine (GUM) trainees. The aim of this study was to evaluate the impact of tendering on GUM trainees. An electronic survey designed by the British Association for Sexual Health and HIV Trainees’ Collaborative for Audit, Research and Quality Improvement Projects (T-CARQ) was distributed to GUM trainees and newly appointed consultants. Eighty-two individuals responded (74% GUM trainees, 25% newly appointed consultants, 1% locum appointed for service). Sixty-three per cent (45/72) had experience of training within a service which was being tendered. Of these, 59% (24/41) felt their training was not considered during the tendering process and 20% (8/41) felt that it was. Forty-four per cent (18/41) felt adequately supported. Thirty per cent (12/40) reported active participation in the tendering process. On a scale of 0 (no impact) to 5 (major impact), the median score for impact of tendering on training was 2. The positive/negative impact of tendering on different training elements was rated: other than management experience the overall impact on all parameters was negative, namely morale, senior support and education. In conclusion, this survey describes the variable impact of service tendering on GUM training. Our recommendations for maintaining training standards despite tendering include actively involving trainees and education partners, inclusion of specialist GUM training in service specifications, development of guidance for commissioners and services for the management of GUM training within tendering.

Reasons for transferring HIV care in London

People living with HIV in England, as well as non-UK born and individuals without residency, can access free HIV care at any service in England. We investigated reasons for transfer of care to three London HIV units by asking all patients transferring to fill in a questionnaire exploring reasons for leaving their previous centre and reasons for choosing the new service. A total of 111 patients completed the questionnaire. The majority of patients transferred from abroad to London HIV units, compared to within the UK. The main reason for leaving their current service was location, which was also the main reason for choosing the service they transferred to. The results of this audit can be used to improve all services to ensure any concerns patients may have are eliminated and provide healthcare tailored to patients’ needs.

The potential impact of new national guidance on primary prevention of cardiovascular disease in people living with HIV.

Cardiovascular disease (CVD) is the leading cause of death in England and Wales. As people living with HIV (PLWH) age, proactive management of CVD risk factors is crucial. The long‐awaited draft guidelines for CVD from the National Institute of Clinical Excellence (NICE) propose lipid modification (with statins) and lifestyle modification for 40–74 year olds with >10% (previously >20%) 10‐year risk of CVD using QRISK2. We currently use Framingham so compared 3 CVD risk calculators in our cohort and analyzed the impact of a change in CVD threshold on the proportion of our patients who would need intervention.

MSM-photodetectors based on AlxGa1−xN/GaN heterostructures grown on Si(111) by molecular beam epitaxy

Structure growth, fabrication, and characterization of AlxGa1−xN based metal-semiconductor-metal (MSM) photodetectors grown on Si (111) substrate by plasma-assisted molecular beam epitaxy (PA-MBE) are presented. X-ray diffraction (XRD) measurements revealed that the sample I (Al0.24Ga0.76N/GaN) and sample II (Al0.43Ga0.57N/GaN) were epitaxially grown on Si substrates. Full width at half maximum (FWHM) for samples I and II were equal to 0.69 and 0.65° respectively. The Schottky barrier height and ideality factor for samples I and II were equal to 0.60, 0.67 eV and 1.29, 1.32 respectively. Maximum peak responsivity for sample I was 0.123 A/W at 305 nm and for sample II, maximum peak responsivity was 0.864 A/W at 275 nm.