Richard Lau

Access to dental care for HIV patients: does it matter and does discrimination exist?

A number of surveys highlight a shortage of dentists in the UK. There is also evidence of discrimination against those with HIV reported within the dental profession and service users. We decided to assess the extent of this problem in our HIV outpatients by conducting a cross-sectional survey, asking them to complete a questionnaire exploring issues related to dental care access, and using clients attending the routine genitourinary (GU) medicine outpatient clinic as controls. A total of 241 outpatients completed the survey, of whom 51 (21%) were HIV patients. Significantly, more HIV patients reported difficulty registering with a dentist than GU patients (58.8% versus 18.2%, χ2 with Yates correction = 8.76, P = 0.0031). They also report significantly more dental health problems compared with controls (54.9% versus 32.1%, χ2 with Yates correction = 8.02, P = 0.0046). In total, 34.6% of HIV patients who had declared their status to a dentist thought that it had negatively impacted on their care, with 6.2% being refused treatment. Our small survey confirms that discrimination in relation to access and level of dental care exists, with black African women being at most risk. Efforts are needed to raise professional standards and HIV awareness to prevent continuing inequalities in dental care provision.

Tamoxifen in antiretroviral-associated gynaecomastia

Gynaecomastia arising in the context of antiretroviral therapy for HIV infection presents a number of challenges in diagnosis and management. We describe a thirty year old gay man with rapidly developing breast enlargement who was successfully treated with the anti-oestrogen tamoxifen.

Screening for asymptomatic chlamydia in women – how often would gonorrhoea be missed?

Resistance of Neisseria gonorrhoeae (GC) to azithromycin is increasing. The dose of azithromycin used for treating uncomplicated genital chlamydia may be subtherapeutic for GC and contribute to gonococcal resistance. The National Chlamydia Screening Programme (NCSP) does not routinely screen for GC but advises further testing of clients with symptoms. This will miss asymptomatic cases. We conducted a case-note review of 100 women aged 16–24 years diagnosed with chlamydia and women aged 16–24 years co-infected with GC and chlamydia, who attended a London genitourinary clinic from 1 October 2004 to 30 September 2005. There were 559 chlamydia diagnoses; 38 (7%) were co-infected with GC. Those co-infected were younger: mean age 18.9 versus 20.3 (P = 0.005). They were also more likely to have symptoms: 28/38 (74%) versus 50/94 (53%) (P = 0.03). Two of 10 women with asymptomatic GC were contacts; meaning that eight cases of asymptomatic GC would have received subtherapeutic treatment. In conclusion, additional testing for GC should be considered in local NCSP protocols where there is a high prevalence of both infections.

An audit of HIV care in English prisons

Previous studies have highlighted disparities in care and outcomes in HIV-positive prisoners compared to HIV-positive individuals in the population. We audited clinical outcomes of HIV-positive prisoners accessing care in 2011. Public Health England were notified of 161 prisoners with HIV in the time period studied. Audit proformas were sent to clinics reporting prisoners to the genitourinary medicine clinic activity dataset in 2011. Thirty-two clinics responded. Data for 151 HIV-positive prisoners were reported by 12 clinics, with the other clinics not reporting any prisoners. Outcomes were compared to a previous audit, British HIV Association (BHIVA) and the National AIDS Trust guidelines. Initial CD4 counts were available for 101 patients, of which 42/101 had CD4 <350 cells/mm3. At reception, viral load data were available for 95 patients, of which 74 were on antiretroviral therapy. Of these, 50/74 (68%) had VL <40 copies/ml. Fifty-one per cent of those on highly active antiretroviral therapy were seen in a specialist clinic less than four weeks after reception. Urgency of referral to a specialist HIV clinic was not related to CD4 or viral load. Twenty-two per cent had hepatitis C co-infection. Clinical outcomes have improved since the last audit but further opportunities exist to optimise care in prisons.

HIV in prisons: the London experience

The commissioning of health services for all prisoners in publicly run prisons in England was transferred to local Primary Care Trusts in April 2006, pledging to provide an equivalent standard of health care as that in the community. We reviewed our experience of providing a specialist in-reach HIV service by performing a retrospective case notes review of all HIV-positive prisoners who accessed care from the prison genitourinary medicine service in three London prisons. A total of 112 HIV-positive prisoners were seen by the prison health-care service between April 2004 and 2006. This is the first study to look at how well HIV services are being provided during this transitional period of commissioning health services and provides insight into the challenges facing prison health-care providers. Good HIV outcomes are possible in prison but frequent transfers within the prison system and lack of effective HIV training among prison staff represent barriers to good care.

Extensive genital warts associated with HTLV-I infection.

This is the first report of infection with HTLV-I associated with severe condylomatosis. Assessment of atypical or extensive genital warts should include testing for this retroviral infection.

Homosexual men, HIV, and sexual risk in 2001.

Editor,—A 33 year old homosexual white male attended an HIV outpatient clinic as an urgent case. He was a healthcare worker involved at a senior level in the care of HIV positive clients and had himself received an HIV diagnosis in 1994. Antiretroviral therapy had commenced in 1998 with a combination of didanosine, stavudine, and nevirapine. This was well tolerated and brought about rapid and sustained viral suppression and a significant increase in CD4 count. The client had been an irregular attender and had often collected repeat prescriptions without medical review. Significantly, no details of his sexual history were recorded for the 6 years following diagnosis, although the existence of a partner was acknowledged in the month before his acute presentation. He attended with a 2 week history of fever in the absence of any other symptoms. On examination he was pyrexial with a temperature of 38.8°C. A 1 cm raised nodule on the centre of the dorsum of the tongue was noted. There was no apparent regional lymphadenopathy. Requests for viral and bacterial culture …

The Genitourinary Medicine Taster: an introduction to GU and HIV medicine for UK trainees

The Genitourinary (GU) Medicine Taster was established by Dr Richard Lau at St Georges Hospital in London in 2009 following the introduction of Modernising Medical Careers in the UK and subsequent concerns that trainee doctors applying for specialist training may have limited experience of their chosen specialty. This 2-day educational programme aims to provide junior doctors with an insight into GU medicine before they apply for specialist training. Five GU Tasters have been organised to date—the first three at St Georges, one in Birmingham, and one in conjunction with the London Deanery. The forthcoming GU Taster will be held in London from 31 October to 1 November 2012 and is organised by Dr Candice McDonald (GU Medicine Consultant, Kings College Hospital) and Dr Sheel Patel (Locum Consultant in Sexual Health and HIV, Imperial College Healthcare Trust). Over the years the structure of the GU …

P192 What career choices do trainees make after attending the GU medicine taster

Background The GUM taster (running annually in London since 2009) is a 2-day educational programme for junior doctors before they apply for specialist training. It is popular and oversubscribed, receiving excellent feedback. We sought to investigate the career choices made by trainees who had attended previous GUM tasters. Methods All trainees who had attended one of three previous GUM tasters were contacted about their career progression. Four questions were asked, covering: (1) current specialty, (2) current year of training, (3) career choices/plan, (4) reasons for choice of specialty. Results Trainees were contacted by email and telephone, response rate 86% (90/105). Trainees currently in specialty or GP training (52%, 47/90) are listed below: The remaining trainees (43/90) were in: non-training clinical posts/working abroad (21), still in F2/CT1/CT2 (19), clinical fellowships (2) or had left medicine (1). Of these, 37% (16/43) planned to apply to GUM as their first choice specialty; with 26% (11/43) planning to apply for GP training. 71% (15/21) of trainees planning a career as a GP wanted to continue with GU as a specialist interest. Reasons given for choosing GU medicine included interest, work-life balance, opportunities for research/work abroad, lively colleagues, diverse patients and avoiding general medicine (see abstract P192 table 1). Abstract P192 Table 1 Delegates choosing GUM as a speciality following taster day Specialty Number of trainees (% choosing specialty) GUM 17 (36) GP 10 (21) Microbiology/radiology 3 each (6) ID/Public health/Surgery/O&G 2 each (4) Dermatology/oncology/geriatrics/rheumatology/ACCS/psychiatry 1 each (2) Total 47 Discussion 37% (33/90) of those attending our GU Tasters were either already in GU training or considering applying for GU as their first choice specialty. In 2011, the Taster was successfully organised in London and in the Midlands (for the first time). The course has allowed trainees to be better informed about the specialty and has highlighted GU medicine as a popular alternative or additional career option for many.

HIV point-of-care testing pitfalls

When counselling patients for postexposure prophylaxis after sexual exposure, we may need to inform them that the efficacy may be low, especially if the patient also had risks prior to the 72 hours between exposure and treatment. The use of a point-of-care test, as well as fourth generation HIV tests and HIV RNA in combination, can still miss seroconversion in the ‘eclipse’ phase of the infection as these tests are not designed to detect the earliest phase of infection.