In 2005, half of people with HIV in the UK had disclosed status to primary care

An analysis of primary care records suggests that at least half of people with diagnosed HIV infection had disclosed their HIV status to their general practitioner (GP), Hannah Evans and colleagues report in the December issue of Sexually Transmitted Infections. The researchers also examined rates of HIV testing in primary care, and found that while the number of tests has increased substantially since the mid-1990s, the total remains low.

People living with HIV in rural areas outside London were especially likely to make use of GP services. People with disclosed HIV go to primary care as often as people in the general population, but a significant proportion of GP prescriptions have the potential to interact with antiretroviral medication, leading the researchers to call for better communication between patients, GPs and HIV specialists.

The researchers used the UK General Practice Research Database to analyse use of primary care services between 1995 and 2005. This is a large database derived from computerised clinical records produced during consultations. In 2005, there were records for 2.8 million patients at several hundred GP practices, a sample that is broadly representative of the UK population.

If HIV–positive status was recorded in primary care records, this would appear in the anonymised research database. The prevalence of patients known to have HIV was compared with the number of people with diagnosed HIV in the UK (using data from SOPHID, the Survey of Prevalent HIV Diagnosed).

In 2005, almost 1,200 patients in the database were known to have HIV. Extrapolating from this, the researchers calculate that 51% of HIV–positive people in the UK had their HIV status recorded in their primary care record.

Surprisingly, this proportion had changed little between 1995 and 2005. Nonetheless, more recently there has been a considerable push for people with HIV to use GP services, and it is possible that in 2009 the proportion of known HIV–positive patients would be higher still.

London residents were the least likely to have disclosed to a GP. In 2005, 42% of Londoners and 60% of non–Londoners had disclosed their status. (In 1995, the figures were 36% and 69% respectively.) Moreover, as adult patients got older, they were more likely to disclose their status.

The database does not collect data on either ethnicity or sexuality, making more detailed analysis of GP uptake by demographic group impossible.

In 2005, men with known HIV had an average of 4.2 consultations each year, and women had an average of 5.2 consultations. Around three quarters were face to face consultations with the GP; others were with nurses, by phone or were home visits.

Consultation rates increased with increasing rurality. The authors note anecdotal evidence that if the HIV clinic is far from a person's home, he or she is more likely to make regular use of primary care services.

Prior to the widespread use of combination therapy, consultation rates were higher, but in this decade rates have been comparable to people in the general population of the same age and gender. Costs have also declined since the mid–1990s.

GPs were often aware of mental health problems in their patients. In 2005, 37% of men and 27% of women had been recorded as having mental health symptoms at some time since their HIV diagnosis.

The authors examined drugs prescribed by the GP and compared these to a list of drug classes that have the potential for adverse interactions with anti–HIV drugs. A total of 17% of prescribed drugs could interact dangerously, although the authors stress that the potential for an interaction may have been verified by a specialist or indeed the prescription may have been initiated at an HIV clinic and continued by the GP.

The authors' main concern is that if those HIV–positive patients who have not disclosed their HIV status are prescribed a similar range of drugs by their GPs, then adverse interactions are likely. In this study, commonly prescribed drugs with this potential were benzodiazepines, anti–inflammatories, antacids and anti–depressants.

The researchers believe that the frequent use of primary care seen in this population lends support to the view that GPs can play a major role in the maintenance of health of people with HIV. Before combination therapy there was little interest from people with HIV in having care shared between GPs and HIV specialists, but the authors believe this issue should now be revisited.

They note that whereas the GP used to have a role of supporting the patient through the process of declining health and death, the focus is now on holistic and preventive care. "The provision of smoking cessation advice, blood pressure, lipid control and contraception needs to be addressed if HIV–positive individuals are to maximise the opportunities to improve quality of life and increase lifespan afforded by HAART," they write.

HIV testing in primary care

Between 1995 and 2005, the number of HIV tests recorded in primary care notes increased 11–fold for men and 19–fold for women (excluding antenatal tests). Nonetheless, rates remain low at 71 tests per 100,000 person–years for men and 61 tests per 100,000 person–years for women.

GPs were most likely to arrange testing for young adults. Moreover, people living in London were twice as likely to test as those outside London. Those in non–urban areas were the least likely to test, and women in deprived areas were more likely to test than those in more affluent areas.

The authors note that antenatal testing increased at a far greater rate during the study period (129–fold), demonstrating that an expansion of HIV testing in primary care is possible, but has not taken place outside the antenatal context.

In an accompanying editorial, the London GP Richard Ma notes that despite advice from the Chief Medical Officer in 2007 and revised HIV testing guidelines in 2008, there is a lot to be done to expand testing in primary care.