Dr David Asboe
Posted 22nd Sep 2016
What do high quality HIV services look like and how do we achieve and sustain these? Much attention over recent years has been given to the “cascade of care” which demonstrates the proportion of people living with HIV (PWLH) who meet certain points in the diagnosis to treatment pathway, starting with the proportion of PWLH who are diagnosed all the way through to the proportion who are on suppressive antiretroviral therapy (ART). Recently WHO has adapted this for their 2020 targets, 90, 90, 90; 90% diagnosed, 90% on sustained ART, 90% virally suppressed.
Looking at figures from Public Health England (PHE), it seems that care in the UK is shaping up reasonably well. Although the undiagnosed fraction at 17% is too high it is reducing and there is a sense that with new technologies like home sampling along with new strategies like expanded testing outside of sexual health clinics we are beginning to get some traction. Retention in care, and the proportion on ART and with an undetectable viral load are both at, or above, 90%. Furthermore a recent study has demonstrated that these later two outcomes are consistent across different groups including men who have sex with men (MSM) and people from black African communities (1).
However, if we look further there is cause for real concern. While late diagnosis has declined between 2010 and 2014 from 38 to 29% in MSM, rates in heterosexuals have shown only very small reductions (from 63 to 61% in men and 58 to 52% in women). Marked regional differences persist with late diagnosis at 48% in the north of England compared with 33% in London. The consequences of this are a matter of life and death. Mortality in the year following a late diagnosis is 10 fold higher. These differences are huge, not only in relative but also in absolute terms. Of the 613 people with HIV who died in 2014, most were diagnosed late (2).
While HIV testing in sexual health clinics is pretty comprehensive in MSM, rates are suboptimal in heterosexuals (2). More than eight out of 10 clinics report testing coverage which is below the British Association for Sexual Health and HIV (BASHH) standard of 80%. Furthermore, we know that key heterosexual populations, especially black Africans, do not in general attend genitourinary medicine (GUM) clinics. Instead of expansion of HIV testing into community settings the programmes that do exist seem to be under continual threat. Meanwhile there is no reliable, comprehensive data about testing in secondary care (especially emergency departments and acute admission units) or critically what is happening in primary care either in relation to indicator condition testing, screening of key populations, or universal testing offer to new registrants in high prevalence areas. Although the proportion of people newly diagnosed who were tested in these settings is increasing, the rate of change is slow.
Current commissioning structures contribute to this fractured picture. There is a nationally commissioned postal testing service offering free HIV tests in participating regions that has been running for approximately one year, accompanied by a variety of centrally funded HIV prevention projects some of which have a testing focus. However this is a significant reduction compared to a couple of years ago. Local authorities have, since 2013, commissioned sexual health services. Funding here has also been reduced with in-year cuts (2015/16) and a five-year programme of reductions that will negatively impact HIV testing. There are anxieties about what will happen when the public health budget loses its ring-fencing. London has embarked on a transformation project which will see a significant proportion of the STI and HIV screening move to online provision. While this innovation will be welcomed if it improves access, it is untested, certainly at this scale. Lastly, commissioning of HIV testing by clinical commissioning groups (CCGs) in primary and secondary care is at best ad hoc.
The tectonic plates of commissioning, may however be shifting. Tantalisingly the introduction of sustainability and transformation plans (STPs) offers the possibility of more joined up, collaborative commissioning within 44 STP footprints. There is talk of “the health and care organisations within these geographic footprints working together to develop STPs which will help drive genuine and sustainable transformation in patient experience and health outcomes in the longer-term. The footprints should be locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to deliver the services”(3). However, there are very serious concerns also. To date STPs have been developed without transparency, have focussed on massively reducing costs, and have not addressed issues relating to sexual health, nor HIV prevention, testing, treatment or care.
More positively there are other opportunities coming. Revised NICE HIV testing guidelines in addition to updated BHIVA/BASHH testing guidelines are both due in the next 3-6 months. These will provide impetus for renewed focus and effort.
Lastly, although the cascade of care has highlighted diagnosis, access to care and antiretroviral treatment as the important parameters, the fact that 1-year mortality is so much higher in late presenters should also prompt us to assess whether we are doing all that we can to safely support the newly diagnosed through this critical period. Do late presenters have timely and appropriate access to highly specialised clinical care, including in-patient services? Are we developing and maintaining the specialised knowledge and skills that are required? What about access to social and peer support? How we organise these services in both high and low prevalence areas is critically important. With the best will in the world a proportion of people with HIV will present late and it must be possible to reduce the excess mortality that is seen in this group.
(1) Click here for the ‘HIV New Diagnoses, Treatment and Care in the UK 2015 report’
(2) Z Yin, S Croxford, A Skingsley, A Brown, S Conti, V Delpech, A Presanis, D DeAngelis, Quality of HIV care in the United Kingdom is excellent and improving: over 80% of diagnosed patients are virologically suppressed. HIV Medicine, 2016, 17 (S1); 3-13
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