A case notes review from general practices in inner London has shown that there is still room for improvement in the management of patients with HIV, particularly in the coding of ART, prescribing of drugs with potential interactions and timely diagnosis.

A total of 31 out of 44 (70.5%) GP surgeries in Hackney took part in the study. Representatives from each practice performed a retrospective case notes review.

There were 1,022 patients confirmed as HIV positive across 31 practices. Of these 954 were aged 15-59, suggesting a prevalence of 6.2/1,000 for this age group which is lower than expected from national surveillance data for HIV prevalence in Hackney (8.2 per 1,000 in 2013). The authors suggested that this discrepancy could be explained by non-disclosure by patients.

Clinic letters and documentation from HIV specialists were identified for 895 of 1,022 (87.6%) patients; only 698 (68.3%) had at least one letter within the previous 12 months.

Even with available information, documentation of ART in GP notes was poor.

• Although 787 of 1,022 (77.0%) patients were known to be on ART only 413 (52.5%) were coded.

• There were 111 (10.9%) cases where it was clearly stated that ART was not required for treatment.

• The remaining 124 (12.1%) had no record of ART either in the notes or clinic letters.

Overall 32 of 787 patients (4.1%), were co-prescribed drugs that had specific contraindications with ART. These included:

• Intranasal or inhaled mometasone/ fluticasone/budesonide with a protease inhibitor: 14 patients (1.8%)

• Simvastatin with ART and/or a protease inhibitor: 13 patients (1.7%)

• Proton pump inhibitors with either atazanavir or rilpivarine: 5 patients (0.6%)

A total of 89 patients were eligible for a retrospective review of events occurring pre-diagnosis.

They attended a total of 716 face to face consultations with a GP over the two years prior to an HIV diagnosis; 123 of these were specifically for HIV indicator conditions.

• Fifty one (57.3%) had presented with symptoms compatible with at least one indicator condition, but only 17 (33.3%) were subsequently diagnosed with HIV by their GP.

The most common were:

• Lymphadenopathy of unknown cause 25 (20.3% of all consultations)

• Bacterial pneumonia 22 (17.9%)

• Unexplained weight loss or chronic diarrhoea 22 (17.9%)

Overall, 25 of 89 patients (28.1%) were diagnosed in primary care, compared with 10.4% identified in BHIVA’s 2010 national audit.

CD4 counts at diagnosis were available for 60 patients. Of these 34 (56.7%) were diagnosed late with counts < 350. Eighteen of 25 patients diagnosed in primary care had CD4 counts available; 12 (66.7%) were classed as late diagnoses, compared with the national average of 42%.

This study is the first of its kind to evaluate the safety aspects of primary care provision of treatment to patients with HIV with regard to drug interactions. It also adds to other research about missed opportunities for early diagnosis of HIV in patients with indicator conditions who present in primary care.

However, the authors missed a golden opportunity to consider the health promotion and disease prevention activities that take place in primary care such as: influenza vaccinations, smoking cessation, cardiovascular health checks and cervical cytology for women.

Dr Richard Ma

• Wellesley R, Whittle A, Figueroa J. Does general practice deliver safe primary care to people living with HIV? A case-notes review. Br J Gen Pract 2015; DOI: 10.3399/bjgp15X68905