Primary care teams can make a valuable contribution to counselling, testing and treatment for HIV, a systematic review has shown.

The authors looked at various shared-care models of HIV involving primary and secondary care.

A literature search was carried out using PubMed, Medline and EMBase for comparative studies or randomised trials published between January 1996 (the year HAART was introduced) and April 2011, in the English language.

The inclusion criteria were: involvement of primary care including prevention, diagnosis and treatment; HAART involved as part of treatment in either intervention or both intervention and control arms. Eleven studies that met the inclusion criteria were included in the systematic review.

Counselling and testing for HIV in primary care demonstrated reduced rates of HIV vertical and discordant infection when compared with usual care. Cost-effectiveness analysis showed a universal screening strategy was more cost-effective than an HIV-risk screening approach but only when the prevalence of HIV and risks are relatively high and tests are inexpensive.

Analysis for treatment and care of HIV in primary care showed either no difference in adherence compared with specialist care, or that it was better in primary care. There was no significant difference in virological failure rate between the two settings. A cost-effectiveness analysis suggested there were lower average costs for home care with chemotherapy and infusion therapies in primary care.

Studies on HIV prevention in perinatal care showed a reduction in vertical transmission and perinatal infection in intervention groups that participated in a prevention programme compared with no interventions. A cost-effectiveness analysis of HIV prevention compared primary care clinical providers with specialist care, mixed care and standard care; the primary care approach was the most cost-effective in prevention of HIV in patients especially in areas of high HIV prevalence.

This review was limited by: the small number of included studies; the limited generalisability of the findings (primary care is not uniform worldwide); reporting bias; selection bias; small sample sizes and assumptions made in the cost-effectiveness analyses. However, it does show that there are no adverse clinical outcomes for HIV counselling, testing and treatment in primary care; also, cost-effectiveness studies were largely in favour.

The World Health Organization recommends that all levels of healthcare systems, including primary care, should be involved in testing, counselling and follow-up of people living with HIV. There is no consensus as to the best approaches for primary care to integrate with specialist services to care for people with HIV.

The time has come to consider moving to a shared-care model for HIV. However, the challenge of breaking down stigma so that people with HIV disclose their status to their primary healthcare team still remains a barrier for good care in the UK.

Dr Richard Ma