London guidelines hiv

These Guidelines were developed by the European AIDS Clinical Society EACS , a not-for-profit organisation, whose mission is to promote excellence in standards of care, research and education in HIV infection and related co-infections, and to actively engage in the formulation of public health policy, with the aim of reducing the HIV disease burden across Europe. The EACS Guidelines were first published in , and are currently available in print, online as a pdf and web-based version, and as a free App for both iOS and Android devices.

The Guidelines are translated into several different languages and are formally revised at least annually for the electronic version and biennially for the printed version. The electronic version can, however, be updated at any time if the panels consider it necessary. The EACS Guidelines cover a relatively large and diverse area geographically, with different national levels of access to care. We aimed to answer the following three questions: a Is there a difference in outcomes between the RHIVA trial intervention and its post-trial implementation?

All adults aged 16 and above registered with a general practice were included. We conducted a service evaluation comprising a pragmatic cohort using an interrupted time series analysis ITS to examine the longitudinal impact of the implementation in the borough. HIV testing, diagnosis and CD4 count at diagnosis data were collected for the period between April 01, and December 31, The study utilised secondary anonymised data for which approval was granted from Camden and Islington NHS Research Ethics Committee, London and no informed consent from patients was required.

Practices were also able to offer rapid testing in other clinical encounters, such as contraception or sexual health screening appointments.

Forty-five practices were operating at the beginning of the trial, including 40 practices that took part in the trial and five practices that declined participation.

Of the latter, one practice closed during the trial period resulting in 44 practices available during implementation. Forty-two of 44 practices were included in this analysis; two practices were excluded: one trial intervention practice closed, and one comparator practice offered walk-in services to homeless people resulting in disproportionally high testing rates compared to their small practice list size see Fig.

Of the 44 practices invited to participate in the implementation, 20 practices had received the intervention during RHIVA2 trial intervention practices and 24 had not 20 trial control practices, and 4 non-participating practices see Fig. A total of 19 practices were trained, including 13 de novo trained practices 12 trial control, 1 non-participating practice and six trial intervention practices for whom this implementation constituted a reinforcement, i.

Since this work focuses on evaluating the impact of the implementation intervention, in comparison to the trial intervention or no intervention, we stratified the practices into three cohorts of interest:. Characteristics of practice cohorts studied during three periods: pre-trial April to March , trial Apr to Aug , and implementation September to December All practice and patient data for these periods are shown. Practice cohorts included in the interrupted time series and difference-in-difference analyses are trial intervention practices including their pre-trial control highlighted in royal blue , implementation practices including their pre-implementation control highlighted in dark blue and implementation comparator practices and their pre-comparator control highlighted in light blue.

This evaluation demonstrated evidence of late diagnosis in general practices preceding the trial. CD4 count at the time of diagnosis were included. The study has been reported in accordance with the STARI reporting guidelines for implementation studies [18]. We constructed time series of the HIV testing data, combining data from serology and rapid tests, HIV diagnosis and CD4 count associated to diagnosis separately for each of the three practice cohorts between April and December Using the data, we truncated the month observation period into periods of pre-intervention and intervention as per Table 1.

To aid visualisation of the temporal trajectory of testing and diagnosis rates, we smoothed the corresponding time series of the pooled monthly data for each group using a symmetric moving average filter with span 5 testing data and 8 diagnosis data.

We note that we only had 12 months of pre-trial data, whereas we utilised 28 months of trial, pre-implementation and implementation data. These data sizes are considered sufficient for statistical significance testing [ 19 , 20 ]. Smoothed time-series of three outcomes: HIV testing rate a , HIV diagnosis rate b and c CD4 count at diagnosis over the period April to December across 19 trial intervention practices royal blue line , 13 implementation practices dark blue line and 10 comparator practices light blue line.

The vertical red lines denote the times of the start of the trial intervention and the implementation respectively. For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article. We used mixed effects negative binomial regression models with random intercepts for GP practices and an offset term for practice size number of registered patients to analyse each outcome separately.

Details of the statistical analysis are presented in Appendix A. Baseline characteristics were similar for sex, age, and ethnic origin across all three practice cohorts Table 1. Table 1 shows that in implementation and comparator practices, people aged 50 and above and people of black African or Caribbean origin were underrepresented among those tested.

There was less evidence of such underrepresentation in trial intervention practices. Across all practices and over the entire month study period April to December , 55, people had an HIV test, of which 45, had a serology test and 10, a rapid test Table 2. Some people may have received both. Among the three cohorts, 65 people were newly diagnosed, including 13 people three diagnosed by rapid testing in implementation practices, 41 11 diagnoses by rapid testing in trial intervention practices, and 11 in comparator practices Table 2.

During the implementation period, a total of 26 patients had a reactive test result recorded on the EMIS template; of which 10 were confirmed HIV positive true positive , two were confirmed HIV negative false reactive , two patients were known to Homerton Sexual Health to be HIV positive, and one patient was unobtainable for confirmatory testing; the remaining 11 reactive results were entry errors. Three patients had an indeterminate result recorded; two were confirmed HIV negative, and one patient was unobtainable for confirmatory testing.

Table 3 contains the testing rates, diagnosis rates, and mean CD4 counts in the pre-implementation and implementation periods, by cohort. Testing rates rose in all three cohorts, but were greater in trial intervention and implementation practices than in comparator practices.

Testing rates declined somewhat in trial intervention practices after the end of the trial. Diagnosis rates increased in trial intervention and implementation practices, but decreased in comparator practices. Mean CD4 count at diagnosis increased in implementation and comparator practices, but decreased among trial intervention practices.

Confidence intervals for diagnosis rates and mean CD4 counts are wide, reflecting the relatively small number of diagnoses overall. HIV testing and diagnosis rates, and mean CD4 count at diagnosis before and during intervention periods across trial intervention, implementation and comparator practices. These periods are defined in Table 2. EACS Guidelines. The new version of the Guidelines v Interactive website!

Conditions of use of downloaded materials: Permission is granted to download the EACS Guidelines for your own use or reproduce a portion for educational purposes only, provided that the use of such information is accompanied by the general standards for referencing scientific material from third parties, i. Upcoming activities October: 18th European Aids Conference. Educational Programme Training and educating the next generation of clinicians and researchers is an EACS core activity.

This process has been driven by government-imposed budget constraints across the NHS, that since have made no annual increase for inflation. This is approximately 2. Irrespective of drug costs, the primary focus for the guidelines is to outline the best standard of clinically appropriate care. This aspect of the recommendations are guided by a sub-committee which includes key consultants, pharmacists and community advocates.

The recommendations are predominantly focused on first-line treatment. Budget targets can be met from the management of drug choices for people starting treatment, rather than from changing treatment for people who are already on treatment. The exclusive recommendation for raltegravir as an alternative to efavirenz is the most significant new change.

It is also problematic, as raltegravir is a twice-daily drug, and national and regional guidelines since efavirenz was first approved in have consistently recognised the benefit from once-daily treatment. Twice-daily combinations can be very effective for some people. Few differences are seen compared to once-daily combinations, in some clinical studies.

However, by definition, people taking part in these studies have all consented to multiple dose combinations. In real-life settings, the frequency of daily dosing complicates adherence and is one of the key factors for HIV positive people when decide on choice of treatment.

In , access to alternatives to efavirenz now requires an additional level of bureaucracy through referral to a virtual clinic or other multidisciplinary team. A late amendment to the guidelines, noted that this review clinic can be retrospective, making this an auditing process rather than one based on patient care.

There is also a concern that the reasons given to use alternatives to efavirenz or raltegravir are baseline drug resistance or concerns about adherence. HIV positive people should be able to simply prefer a once-daily to a twice-daily combination, if this is important for them, because of how it fits with their life. It should be a preference. However, at the launch meeting for the guidelines on 4th June it was clarified that the guidelines are not designed to restrict access to boosted atazanavir or darunavir, both of which are still expected to be widely used.