Posted 11th Dec 2014
So, dear primary care colleagues – how is your flu immunisation campaign this year? Are you on track for your Care Quality Commission visit? Did you find a locum to cover that colleague who is now involved in the CCG one day a week? Are you negotiating the hoops and hurdles for revalidation? And did you manage to replace that wonderful nurse who retired? How are your QOF outcomes shaping up this year? And, dare I ask, how are your patients, how are your elderly patients, this winter?
As a British GP, now writing from rural KwaZulu Natal (KZN) South Africa (SA) – just as spring turns to summer – I can promise you I feel for you. Certainly, there are challenges here – but they have such a different shape, are on such a different scale, that they remain for me, at the moment, almost refreshing. For example, our own equivalent of a blanket flu immunisation campaign is the need to test everyone for HIV. Nurses or doctors, we must think about it all the time. This makes it easier, in a way, than HIV testing in the UK. There is none of that sense of looking for needles in haystacks in this area where a quarter of adults have HIV; a third of women in antenatal care are infected. It’s a much more resoundingly life-saving activity to diagnose HIV here, than to give flu jabs in the UK (however much of a fan you are of flu imms!). Here in KZN health outcomes are improving dramatically, astonishingly, as more and more people are treated – almost all having their antiretrovirals (ARVs) initiated and prescribed by primary care nurses. If ARVs are used extensively enough, consistently enough, there is even the hope of reducing infectivity and so HIV incidence. We are seeing that maternal to child transmission has plummeted from about 20% to around 3% – no small feat achieved by the nurses working in services where not every patient will have a bed; electricity and hot water are intermittent; the pressures of workload are overwhelming. Watching the nurse pop out from the office to check with every mother leaving maternity with her new baby – does she need the medication? Is it safely in her bag? Can she just explain to the nurse how she is planning to take it? And oh what a lovely baby that is!
Here every primary care clinic has an HIV counsellor. In the UK of course it has long been recognised that there is no need for formal counselling before HIV testing – indeed even self-testing using the internet is sanctioned now in the drive to reduce undiagnosed HIV. But, here in rural SA, it is a less simple matter to do away with counselling when stigma is still commonplace – and when there are plenty of people who think that it is best not to share meals with an infected person.
All health organisations - worldwide - need strategies for HIV testing, but these must, of course, be tailored to context. Around a quarter of people with HIV in the UK are unaware that they are infected. Those who remain undiagnosed are more than 30 times more infectious  than those on suppressive antiretroviral therapy. In addition, the undiagnosed are at risk of being diagnosed late. If only diagnosed when the immunity is rock bottom (a CD4 count of less than 100 cells/mm3, say) then the one year mortality is 7-8% (instead of less than 1%) . So it is pleasing to see that the Royal Free has just joined those hospitals which offer routine HIV tests for adults under 60 admitted for medical care.
So what is the primary care equivalent for a general practice serving the same area? Symptomatic attendees in primary care will offer much less rich pickings for HIV diagnosis and we certainly won’t be testing all of them. To improve HIV diagnosis in this group GPs need to be both familiar with symptoms and conditions that are HIV-associated, and then able to raise the subject and offer the test. Aside from this use of diagnostic testing with symptomatic patients, there are the asymptomatic patients to consider. Screening - offering HIV tests to all newly registering patients - is being commissioned in some high prevalence areas. In addition, opportunistic testing – the offer of a test to those found to be at risk – is another strategy to increase early diagnosis. This depends on routine sexual history taking, routine checking for a history of injecting drug use and also proactive discussions with people from high prevalence countries. Finally, patient request HIV tests – generally a small proportion – need to be encouraged.
So a range of strategies. But how to tailor them to make it appropriate for your local prevalence of HIV, for your own service? How to engage your team - maybe even have some fun - and implement change? How might one GP, or one practice nurse, who felt ‘up’ for doing this with their team be best supported to make things happen?
Before I left the UK I authored a webtool that aims to help you do just that: HIV Testing in Practice – HIV TIPs. Developed by MEDFASH and endorsed by the Royal College of General Practitioners (RCGP), the site will help you assess your learning needs, as well as those of your team. You will be able to update your own knowledge and you will be able to download a range of activities to use with your team – from simple presentations for a clinical meeting through to group activities involving both clinical and non-clinical staff.
When developing the TIPs webtool I hope that I never lost sight of the pressures that are faced in general practice at the moment. So take a break, have a look. You might find an opportunity to bring some zest to your team – while engaging with a really important and interesting clinical topic. Of course, doing this, you might generate material for your appraisal. But what if you even enabled a nurse in your team do the test that diagnosed someone with HIV? Now THAT would be something worthwhile to put in your ‘reflection’ feedback to your appraiser!
Not working in general practice? But know someone who does? Perhaps you are a Public Health Lead in Sexual Health? Or an HIV Specialist? If so - please forward on this link to your primary care colleagues to support use of our website and, most importantly, help increase HIV diagnosis in your area.
 Cohen MS et al, Prevention of HIV-1 Infection with Early Antiretroviral Therapy N Engl J Med 2011; 365:493-505
 HIV in the United Kingdom: 2014 report Public Health England
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