Episode 41: HIV & Sexual Health Part 1

Author: Eoghan Colgan @eoghan_colgan
Special Guest: Rebecca Metcalfe @becksmetcalfe

04/12/19

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Guest Bios

Rebecca Metcalfe

Dr Becky Metcalfe is a Consultant in Sexual Health & HIV Medicine in NHS Greater Glasgow & Clyde. Her special interests include women living with HIV and managing HIV in vulnerable groups. She is part of a team managing an ongoing outbreak of HIV amongst people who inject drugs in Glasgow.

Show Notes

Rebecca Metcalfe is a Consultant in Sexual Health with a specialist interest in HIV, the topic of this episode. Eoghan and Rebecca discuss the current state of HIV infection and treatment, the recent spike in prevalence in Glasgow, and a whole lot more.

TAKE-HOME POINTS

General info:

the virus is still present but there are a range of very effective treatments (all are tablet-based at present)
The majority of people take one tablet a day, and it is a life-long treatment
It is now completely suppressed (with tx), which means:
- it no longer limits their health or life-expectancy
- they cannot pass the virus on through sex
There are different choices for different people, and decisions are made based on:
- the virus itself (some can be resistant to certain medications)
- side effects
- interaction with other medications
- some require being taken at certain times of the day which doesn’t always suit

Recent spike in occurrence:

previously one of the commonest demographics was men having sex with men; incidence in this group has reduced a lot through educastion and preventative measures
in the last 5 years there has been significant increase in diagnoisis and transmission, in glasgow, in:
- people who inject drugs (particularly cocaine), and people who have sex with those who inject drugs
- and they are poeple are typically homeless and have been frequenting glasgow city centre
The reasons are complex:
- there was a prior reluctance to treat this group who tended not to adhere to treatment, which can lead to emergence of resistant viruses
- their chaotic lifestyle affects access to medicine anmd engagement with services
- there was lots of free injecting equipment but people were still sharing
- addiction services experienced significant resource pressures
- increase cocaine injecting - users tend to inject more frequently leading to increased risk of sharing
The discovery:
- positive results go through a shared care team in glasgow and they will try to find affected people and offer services
- they noticed a spike in cases in 2014
How tackling:
- increased HIV testing in Emergency departments, particularly in Glasgow Royal Infirmary shice serves the city centre of Glasgow
- Also increased awareness and testing at other places they frequent for opiate/cocaine treatment or needle-exchange services
- increased education for providers and users (reduce sharing and increase condom use)
- the clinical side have completely changed their service:
  - they realised that this was a vulnerable group, and they had made it difficult for them to access treatment
  - 3 years ago they introduced a mobile nurse that locates affected people on the streets or in hostels, and engages them in care
  - 2 years ago they introduced clinics within homeless services providing full BBV care, shared between ID and GUM services
  - engagement weith community pharmacy teams: most of these individuals are on opiate replacement therapy so can receive anti-retrovirals at the same time
- There is on-going work into injectable treatments

No. 1 piece of advice:

take opportunity in ED to do a HIV test on individuals who inject drugs (unless very recent HIV test <1 month)
- they tend to use ED services mor ethan most others
- the prevalence in Glasgow in injecting drug users is 11%
How to approach:
- ask have they injected drugs in the past 6 months
- ask if they have had a HIV/BBV test before - but this can be unreliable (some think they have when they have not)
  - if injected drugs and never had a test then definitely recommended
- You can tell the patient that you are takingbloods for a wide screen which includes a HIV test
  - always best to gain consent
  - if they so no, then explore why - you should be worried about those that refuse
  - explain the benefits of treatment and that they will be fully supported
- In glasgow - the results are then followed-up by the Shared Care Team at the Sandyford Clinic, and acted on

Relaying Positive Test Results

they have developed great links with community homeless and addiction services, so never struggled to find someone
they then sit them down and discuss/educate
very rarely do people not engage
- remember: they do tend to care about their health but they have other issues which can be prioritised over their health
then make it as easy as possible for them to access the daily treatment

Advice to other cities

don’t get complacent
- there has been a recent smaller spike in cases in Birmingham
- keep up prevention measures: Education and HIV testing
- provide treatment if required: they can be more adherent than people can presume them to be

Pre-Exposure Prophylaxis

Can prevent the acquisition of HIV Through sex
- proven in trials to be effective in heterosexual and homosexual sex
Comnmonly a single tablet which is a combination of two drugs used to treat HIV:
- Tenofovir & Emtricitobine
Scotland is one of the first countries to provide free on NHS
Majoroty who receive are men who have sex with men
- typically tablet taken every day or around the time of sex
It is only licensed for sexual transmission (not in IV drug injectors)
It is not a better option to contraception, rather an additional safety net
- condoms have been around a long-time but HIV numbers were increasing
Side-effects:
- generally very well tolerated
- can affect the kidneys so monitor, and additional caution in tgose with existing renal dysfunction
It is provided through sexual-health services and strict criteria are used: see link below
The feeling is that it doesn’t encourage risky sexual behaviour
- those using it were probably nopt using preventative measures before