HIV-positive people presenting with complications of HIV can be critically ill with life-threatening conditions and require complex care including intensive care. Management for these patients should be provided by an HIV specialist consultant-led multidisciplinary team, frequently in collaboration with other medical specialties. According to Public Health England of the 6095 people diagnosed with HIV in 2015, 39% were diagnosed at a late stage of the infection. People diagnosed late are at increased risk of developing an AIDS-defining illness and continue to have a ten-fold increased risk of death in the year following their diagnosis, as compared with those diagnosed promptly (31.5 per 1000 compared to 3.6 per 1000). One-year mortality was particularly marked among people aged 50 years and over, where one in 16 diagnosed late died within a year of diagnosis. If appropriately managed, people presenting with severe HIV-related complications should expect a good long-term prognosis. Best clinical practice or the management and treatment of HIV-associated opportunistic infections and cancers is outlined in national and international guidelines.
The spectrum of illness seen in HIV-positive patients has changed over the last decade. The use of effective ART in people known to have HIV has led to fewer people requiring inpatient care for immunosuppression-related complications of HIV. To ensure optimal management of these conditions, service provision will need to be delivered via formal networks across geographical areas to ensure that inpatients with advanced HIV have equitable access to best-quality care and advice. Network arrangements will ensure that HIV services maximise critical mass in order to provide adequate experience to achieve optimal outcomes and support training in inpatient HIV care. In addition, long-term survival has led to an increase in a number of malignancies and other end-organ disease. There will be a need for a network to develop agreed pathways for integrated care for those conditions requiring specialist input, such as lymphoma, multicentric Castleman’s disease, co-infection with hepatitis B and C, and end-organ liver and renal disease.
HIV-positive people are living longer and are often admitted to hospital for non-HIV related problems. During hospitalisation they may be seen by a wide range of healthcare staff, some of whom may have limited experience in providing care for people living with HIV. Issues that can negatively impact on patient experience during their stay include fear of breach of confidentiality, fear of stigma and fear of drug errors with HIV medication.
Providers of outpatient HIV care must have documented, agreed pathways to appropriate inpatient services. It is accepted that not all HIV-positive people with proven or suspected complications of HIV require transfer to an HIV specialist unit and they may be cared for safely and effectively locally. They must, however, be supported by immediate and continued engagement with specialist HIV expertise and advice, allowing for early transfer should the complexity of care escalate. Specialist HIV inpatient services must also be in a position to provide support and advice to acute medical services when a patient is clinically unsafe to transfer.