4. Complex HIV care

A combination of an ageing HIV cohort, longer duration of HIV and long-term ART has resulted in a shift from HIV-associated pathology and ill health associated with severe immunosuppression to non-AIDS comorbidities associated with ageing in the general population such as neurological, heart, liver and renal diseases and cancers. HIV services have a key role in screening and monitoring people for complications associated with HIV. Where a service is not in a position to deliver all aspects of HIV related care, it is essential for clinical safety and service sustainability that clear, agreed pathways are established with local or regional specialist and primary care services to allow equitable access and safe delivery of care for people living with HIV. Good communication between services is essential to optimise clinical outcomes and ensure patient safety due to the increase in comorbidities and the complexity of HIV drug–drug interactions.

People living with HIV are at increased risk of certain co-infections, particularly TB, hepatitis B and hepatitis C. Risk factors include immunosuppression associated with advanced HIV in the case of TB, as well as shared routes of transmission between HIV and hepatitis B and C viruses, and higher prevalence of these infections in parts of the world where HIV is endemic, especially sub-Saharan Africa. It is essential, therefore, that people living with HIV are screened for these co-infections both at initial HIV diagnosis and during followup, according to national guidelines. Those found to be co-infected should be referred to specialist services for appropriate treatment.

People living with HIV are also at increased risk of certain cancers, including the three AIDS-defining malignancies (Kaposi’s sarcoma, B-cell non-Hodgkin’s lymphoma and cervical cancer), as well as many other cancers. The care of these patients should be undertaken by a multidisciplinary team, including oncologists, HIV physicians and palliative care physicians where appropriate.

Comorbidities

• Proportion of people living with HIV with a smoking history documented in the last 2 years (target: 95%) and blood pressure recorded in the last 15 months (target: 95%).

• Proportion of people aged over 40 years with 10-year cardiovascular disease risk calculated within 1 year of first presentation (target: 90%), and within the last 3 years if taking ART (target: 90%).

• Proportion of people with documented assessment of renal function, to include serial assessment of creatinine or eGFR measurements, and proteinuria over the last 24 months (target: 90%).

• Proportion of people aged over 50 years and all post-menopausal women and trans men with documented evidence of bone fracture risk assessment within the last three years (target: 90%).

TB

• Proportion of people newly diagnosed with HIV from high- and medium-risk countries with documented screening for latent TB (target: 90%).

Hepatitis B and C

• Proportion of people with documented screening for hepatitis B and C at time of HIV diagnosis or first clinic appointment (target: 95%).

• Proportion of people who are non-immune to hepatitis A or B offered vaccination as per BHIVA guidelines (target: 95%).

• Proportion of people who are co-infected with hepatitis B or C with documented assessment of liver staging (target: 90%) and if ongoing HBV or HCV viraemia, with documented assessment of liver staging in past 15 months (target: 90%).

• Proportion of people with cirrhosis (regardless of cause) with documented hepatocellular carcinoma screening in past 12 months (target: 90%).

Cancer

• Proportion of services with evidence of network arrangements appropriate to a geographical area to ensure that people requiring specialist oncology services have equitable access to best-quality advice (target: 95%).

• Proportion of people diagnosed with a malignancy linked to specialist oncology services (target: 95%).

References: 11, 49, 82–84