Orla McQuillan

Adherence to antiretroviral therapy in pregnancy

Successful interventions to prevent congenital HIV require adherence to highly active antiretroviral therapy (HAART) in pregnancy from mothers and agreement with other interventions including mode of delivery and infant testing. We sought to audit adherence support offered antenatally, adherence with HAART, recommendations for delivery and infant testing in women receiving HIV care at our unit and delivering a child in 2004 and 2005. Of the 32 women identified, an adherence discussion was conducted when commencing therapy in 87% and subsequent visits in 77%. Five women were non-adherent with HAART, one disagreed with recommendations for delivery, and attendance at initial post-natal tests was documented in 61%. In general, the British HIV Association guidelines with regard to adherence are followed. Although numbers in this cohort are small, age, ethnicity and pre-pregnancy HIV diagnosis did not seem to affect adherence, but being therapy naïve and poor adherence may predict non-attendance at infant follow-up.

Acute generalised exanthematous pustulosis induced by Pneumocystis jirovecii pneumonia prophylaxis with dapsone.

We describe the case of HIV-1 infected patient presenting to hospital with a severe cutaneous adverse drug reaction shortly after commencing dapsone therapy as Pneumocystis jirovecii pneumonia prophylaxis. To the best of our knowledge, acute generalised exanthematous pustulosis has not been reported as a reaction to dapsone in the setting of HIV.

Audit of the management of antiretroviral treatment-naïve HIV patients in Greater Manchester, UK.

Summary: We evaluated the management of antiretroviral treatment (ART)-naïve HIV-positive patients in Greater Manchester against the 2005 British HIV association (BHIVA) guidelines. Fifty-seven HIV patients (median age 36 years, 61% males, 53% black Africans) commenced their first ART regimen between 1 October and 31 December 2005. Most of them presented with advanced HIV disease (74% had CD4 lymphocytes <200 and 33% were Centers for Disease Control and Prevention stage C) and 51% commenced ART within three months of their HIV diagnosis. Ninety-six percent had baseline laboratory investigations performed but only 53% had baseline blood pressure estimation. Only 25% had urinalysis performed. A combination of two nucleoside reverse transcriptase inhibitors (NRTI) and one non-NRTI was chosen in 76% of patients. Eighty-two percent of patients had a clinical review and blood tests within five weeks of starting treatment.

Retrospective analysis of the associations and effectiveness of performing therapeutic drug monitoring in pregnant HIV-positive women in two large centres in Manchester

There is no proven benefit for the routine use of therapeutic drug monitoring in HIV-positive pregnant women either for improving viral control or preventing mother-to-child transmission. This analysis reviewed a cohort of 171 HIV-positive pregnant women delivering between 1 January 2008 and 28 May 2013 to first establish which baseline characteristics are associated with having therapeutic drug monitoring performed, and whether therapeutic drug monitoring was associated with improved HIV control during pregnancy or mother-to-child transmission. Therapeutic drug monitoring was performed in 39% (n = 66) of patients; it was associated with baseline characteristics of poor adherence to therapy (therapeutic drug monitoring 23% versus non-therapeutic drug monitoring 10%, p = 0.025) and the use of protease inhibitors (therapeutic drug monitoring 94% versus non-therapeutic drug monitoring 77%, p = 0.005). By multivariate analysis therapeutic drug monitoring was associated with medication alterations during pregnancy (therapeutic drug monitoring 68% versus non-therapeutic drug monitoring 12%, p = < 0.001), but not associated with any difference in viral load breakthrough during pregnancy (therapeutic drug monitoring 12% versus non-therapeutic drug monitoring 7%, p = 0.456) and viral load detectable at birth (therapeutic drug monitoring 14% versus non-therapeutic drug monitoring 9%, p = 0.503). There were no instances of mother-to-child transmission. Therapeutic drug monitoring’s association with medication changes is postulated as partially causal in this cohort. There was no evidence of any association with improved control or reduced transmission of HIV to advocate routine therapeutic drug monitoring use.

P125 “I googled it…”: what is recommended online for the management of vulvovaginal candidiasis?

Background Recently our centre encountered women reporting self-treatment of candidiasis with intravaginal applications of foodstuffs including garlic, vinegar and yoghurt. All patients had a unifying factor of reporting “googling” their therapy. Aim To establish which candidiasis management strategies female patients are most likely to encounter when searching via Google. Method Search history data was collated from Google Trends to identify the ten most popular search terms related to candidiasis in the UK between 15/03/15–06/03/16. These terms, along with term “thrush”, were assessed totalling 11 Google searches. All websites on the initial results page for each search term were accessed to review recommended therapies. Click-through data suggests the vast majority of Google users (>90%) select their chosen website from this first results page. Results 116 search results included 97 (83.6%) advising women about vulvovaginal candidiasis. 96/97 (99%) recommended imidazole therapy first line, all reassuringly advising against oral therapy in pregnancy. Patients were recommended to seek treatment via a pharmacy (72, 74.2%) or their GP (54, 55.7%) rather than attending a genitourinary service (12, 12.2%). The recommendation of natural yoghurt for symptomatic relief was frequent (40, 41.2%), more than using emollients or soap substitutes (27, 27.8%). Unfounded treatments including eating probiotic yoghurts (9, 9.3%), vinegar (8, 8.2%), and treatment of sexual partners (8, 8.2%) were encountered. Conclusions Sensible evidence-based advice is the most prevalent online for vulvovaginal candidiasis. However a number of poorly evidenced therapies are encouraged. This information should be discussed and appropriately challenged during routine management of vulvovaginal candidiasis.

P050 Improving management and partner notification outcomes of women treated for pelvic inflammatory disease (PID) by innovative yet simple bespoke measures

Background PID is a common condition seen at genitourinary clinics. BASHH published NICE approved guidelines in 2011. To improve consistency amongst clinicians we designed a simple aide memoire tick-box sticker. To improve health adviser (HA) contact and reduce “did-not-attend” (DNA) rates we established a HA staffed telephone follow-up clinic Methods We regularly audit both management of PID and follow-up and so were able to compare data (2011–2015) to demonstrate improvements in practice with these changes Outcome Partner notification rates improved from 50% to 67% helped mainly by the telephone clinic as HA documented in all cases whether partners had been screened/treated. 82% had a recording of symptom change, previously 77%. For those followed-up using the telephone clinic proforma this was 100%. Results for the number of named male contacts screened for infection and/or treated have improved (2011 = 0.21; 2014 = 0.38; 2015 = 0.48) and we now achieve above the BASHH target (0.4 – large city centre clinic). Over the past five years introducing these measures into clinic has improved all outcomes except DNA rate which remains stubborn (33% vs 27%). For a large city centre clinic the reasons behind this are complex and varied Conclusions Innovative yet simple measures can be easily introduced which have a positive impact on guideline adherence and also make audit an easier task. With the advent of EPR in many clinics these initiatives should be transferable and aid standardising management across the GU network particularly during this time of change and service integration

P171 Rapid reliable HIV Point of Care Testing

Background Our outreach HIV Point of care testing (POCT) programme changed from 4th generation testing to 3rd generation POCT kits in August 2014, which led to a significantly quicker turnaround time for results and greater convenience for both outreach staff and patients. We continued to confirm all POCT serology by conventional laboratory testing. Aims To compare 3rd and 4th generation POCT in clinical practice and review the need for laboratory confirmation of all samples. Methods The INSTI™ HIV-1/HIV-2 Antibody Test was used for POCT testing at a city centre outreach service from August 2014 until July 2015. All samples were also tested in parallel, in real-time, by standard laboratory tests for HIV. Results were compared retrospectively. Results POCT was provided for 399 patients. 31 patients were excluded. Of the remaining 368 patients, there were 6 true positive results (1.6%) and no false-negatives or false-positives. By contrast, our previous evaluation of Alere Determine™ 4th generation testing, with a sample size of 367, found 3 true positives (0.8%); 2 false positives (0.6%); and 3 false negatives (0.8%), leading to negative predictive value 99.2%; positive predictive value 60%; sensitivity 50%; specificity 99.4%. This was a significant underperformance in clinical practice compared with advertised values. Discussion INSTI™ is outperforming Alere Determine™ in our local experience. We intend to continue using 3rd generation POCT in our outreach programme. Given INSTI™’s performance, the question now raised is can we consider moving away from carrying out backup serology in all cases?

P225 Reach out and test me

Background Saunas have traditionally been where MSM participate in risky sexual activities, contracting high numbers of sexually transmitted infections (STIs) and have been ideal targets for sexual health outreach work. There has however been a recent trend towards private “Chem-Sex “parties arranged through social media. Is sexual health outreach work in the saunas still justified, particularly in these financially pressured times? Aim Comparison of outreach services in a large urban centre in 2011 and 2013. Methods Retrospective case-note review of patients who accessed outreach services July–December 2011 and 2013. Results In 2011, 98 case notes were reviewed. The rate of infection was 28.2%. In 2013, 89 case notes were reviewed. The overall rate of infection fell to 14.6%. However, 46% had never attended our GUM clinic and among these the infection rate was 22%. The comparative rate in MSM attending clinic was 8.7%. Of those new to our services 19% had never attended any GU service and of these 82% had never tested for HIV. Conclusion Our outreach team tested a significant number of patients with a high burden of infection who had never accessed services. However, the team is taken from conventional clinics; due to staff shortages in the clinic, patients are turned away. A balance needs to be found between financial constraints and reducing infection in hard-to-reach populations. Collaboration with voluntary organisations and saunas will be the key to our success. We are currently setting up a Chem-Sex clinic to target evolving at risk populations.

P59 Improving management of pelvic inflammatory disease by using a simple tick-box sticker

Background Pelvic Inflammatory Disease (PID) is a common condition with a reported 1:50 sexually active women in the UK developing it annually. An estimated 1:5 will consequently become infertile. Use of the 2011 BASHH guidelines provides an excellent tool in improving uniformity in treatment and advice provided. Aim To assess improvement in care from two cohorts of patients with PID attending a District General Hospital clinic, at two points, 3 years apart by introduction of a PID tick-box sticker. Method Using a BASHH guideline based proforma, data were recorded and compared between 2 cohorts, the 1st from June to December 2008 (27pts), the 2nd from 2011 (25pts). Results In 2011: STI detection was increased at 48%, from 37% previously, reflecting national trends. 88% received 2 weeks of metronidazole and doxycycline (12% had erythromycin due to risk of pregnancy). None had ceftriaxone as per local guidelines based on this and an additional audit, which revealed very low prevalence of infection with Neisseria gonorrhoeae in the local PID population. Improvements with the introduction of the sticker included number of pregnancy tests performed—80% up from 26% and documentation of provision of written information which rose from 3.7% to 88%. 60% saw the HA at their clinic visit compared to 44% in 2008. Partner notification rates were unaffected with 51.6% of male contacts screened with a STI detected in 44% as opposed to 67% in 2008 with a STI in 37%. N gonorrhoeae was not identified in any presenting woman, nor any screened contact in 2011 and in only one contact in 2008. Conclusion Introduction of a simple measure such as a PID sticker can aid documentation and adherence to correct management. Striving to improve better partner notification with subsequent screening and treatment, should remain a priority. Of note, there were no Gonococcal infections detected in any of our 2011 cohort and this reflects the local prevalence.

P168 Acute generalised exanthematous pustulosis induced by pneumocystis carinii pneumonia (PCP) prophylaxis with dapsone

Background Acute generalised exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction. Most cases are drug related, however the condition has been associated with viral infections. Objective AGEP in the setting of HIV is uncommon. We report a case of AGEP induced by PCP prophylaxis with dapsone. Results A 34-year-old HIV-infected Nigerian woman was admitted to hospital with a 2-week history of a progressing pustular skin rash. CD4 count 1 month prior to admission was 176 cells/mm3 and she had not been taking antiretrovirals since 2008. Three weeks prior to presentation she had commenced Dapsone for PCP prophylaxis. Admission to hospital revealed a fever of 40°C, tachycardia, hypotension and a widespread erythematous papular eruption with overlying pustules. Laboratory investigations revealed; haemoglobin 7.6 g/dl, raised oeosinophils of 0.67×109/l, C reactive protein 144 mg/l and Direct Coombs test was positive. A venous metheamoglobin level was raised at 3.5% and chest radiography revealed subtle consolidation at the left base. Broad spectrum antibiotics and fluids were initiated and Dapsone was withdrawn. Dermatology review raised the clinical suspicion of drug rash with oeosinophilia and systemic symptoms (DRESS) or AGEP. Skin biopsy supported the clinical diagnosis of AGEP. She remained systemically unwell and intravenous hydrocortisone was commenced. Subsequent infective screen for viral and bacterial pathogens was negative. Over the following week the pustular rash began to desquamate with significant improvement. She made a full clinical recovery and subsequently started antiretroviral therapy and atovaquone for PCP prophylaxis. Discussion Drug reactions in the setting of HIV and its treatment are common. AGEP in the setting of HIV has rarely been reported. This case illustrates a less common but important severe cutaneous adverse reaction to recognise in our HIV cohort.