HM Medical Clinic



www.aidsmap.comissue 158 july 2006 why GPs need to be integrated into HIV-positive care page 4 primary care at HIV clinics is your clinic providing GP services? page 14 immunisation guidelines new vaccination guidance for HIV-positive people page 8 does efavirenz cause depression? a new study suggests otherwise page 3 anti-HIV therapy adds thirteen years to post-AIDS survival page 13 LGV continues to spread amongst HIV-positive gay men page 13

aids treatment update july 2006 Some GPs have never been exposed to page 3 This month's Upfront asks whether diagnosed HIV-positive patients because in efavirenz (Sustiva) is the primary cause of the past, HIV clinics have made it easy for depression in people taking this anti-HIV us to use them as a one-stop-shop, negating drug, since a new study from France suggests our need for a GP.
that other factors may be to blame.
This has led to a vicious circle that needs to page 4 In Better practice, we explain why GPs need to be integrated into HIV-positive be broken because some GPs continue to miss care, and examine the barriers - and possible undiagnosed HIV, since they're not HIV-aware.
solutions - to this uniquely British problem.
Besides, sooner or later, we will all require an page 8 Dr Anna Maria Geretti, lead author HIV-knowledgeable GP, because GPs will need of the the most comprehensive immunisation to prescribe medicines that your HIV clinic can guidelines ever produced for HIV-positive no longer afford - like lipid-lowering and adults, explains why HIV-positive people anti-diabetes drugs, and antidepressants.
need special consideration when it comes If you have a GP that already knows about to vaccinations.
HIV issues, you probably live in an area page 12 News in Brief features a calculation where your local Primary Care Trust (PCT) that anti-HIV therapy adds more than provides the 'carrot' of locally enhanced thirteen years to post-AIDS survival. Plus services. This means GPs get paid extra to further details of the current LGV outbreak provide good quality care for HIV-positive in the UK that is disproportionately affecting people. Sadly, many need this financial HIV-positive gay men; why anyone on triple enticement in order to learn more about HIV NRTI therapy should consider changing to and take on HIV-positive patients.
something more potent; and news about a potentially serious heart condition that We need to put pressure on our local PCTs affects one in every 200 HIV-positive people.
to provide locally enhanced services in every area, but until that utopia exists, why not ask page 14 Is your HIV clinic providing GP services? Compare their policies to the six your clinic, or other HIV-positive people, to UK clinics who answered our snapshot survey help you find a local GP that is HIV-aware.
regarding the provision of primary care at HIV clinics.
medical advisory panel NAM is a charity that exists to The publishers have taken all such support the fight against HIV and care as they consider reasonable in Professor Janet Darbyshire AIDS with independent, accurate, preparing this newsletter. But they aids treatment update Heather Leake Date MRPharmS up-to-date and accessible will not be held responsible for any editor Edwin J Bernard information for affected inaccuracies or mis-statements of sub-editing & proofreading Professor Brian Gazzard communities, and those working to fact contained herein. Inclusion in Professor Frances Gotch support them.
this newsletter of information on production Thomas Paterson Dr Margaret Johnson any drug or clinical trial in no design Alexander Boxill For more information, and details way represents an endorsement of printing Cambrian Printers Dr Adrian Palfreeman of our other publications and that drug or trial. This newsletter Kholoud Porter PhD services, please contact us, or visit should always be used in copyright NAM Publications our website,
conjunction with professional 2006 All rights reserved Professor Jonathan Weber medical advice.
charity number 1011220 AIDS Treatment Update For more information about ATU's was founded by Peter Scott medical review panel, please
contact details Lincoln House, 1 Brixton Road, London, SW9 6DE, UK email: [email protected] The Derek Butler Trust

aids treatment update july 2006 Does efavirenz cause depression? by Edwin J Bernard Efavirenz (Sustiva) is one of the most similar people who continued to take popular anti-HIV drugs in the UK and, their PI-based treatment combination.
out of all the non-nucleosides During the first year of the study, a (NNRTIs) or protease inhibitors (PIs) similar number of people taking either available, it is the drug that people efavirenz or a PI were diagnosed with starting therapy for the first time are depression. Although more people on most likely to take.
efavirenz experienced side-effects bad Although it is well established that the enough to switch away from the drug, most common side-effects of efavirenz this was due to bad dreams, dizziness occur in the central nervous system, and headaches, and no-one stopped and studies have shown that up to treatment because of depression.
50% can experience side-effects In fact, rather than efavirenz being efavirenz-based regimens resulted in relating to sleep disturbance during the linked to depression, the investigators excess anxiety or depression," the first few months of treatment, there found that both younger age and a have been conflicting findings on the previous bout of depression were link between efavirenz and the linked to a greater risk of developing Nevertheless, last year a small study development of depression.
depression during the study, regardless from Spain found that people who continue to experience efavirenz's Some clinical trials have found that of which anti-HIV drugs they were psychological side-effects in the longer the psychiatric side-effects of efavirenz taking. "Contrary to the idea widely term are much more likely to have – including depression, suicidal held among HIV-infected patients, physicians, and researchers, our data higher than normal levels of the drug thoughts, aggression, paranoia, and showed no evidence of efavirenz in their blood. Individuals with a blood mania – are very rare. Depression has having an effect on the risk of plasma concentration of efavirenz been reported in around 2% of people depression or suicide in the first 48 above 2.74µg/ml at any point during on efavirenz and other psychiatric weeks of use – or even up to 36 the 18 month study were almost six side-effects have been reported in months of use," the researchers wrote.
times more likely to develop fewer than 1% of people on the drug.
side-effects that included depression or Around one person in every hundred A study published last November sleeping problems than those with discontinued efavirenz due to attempted to examine efavirenz's consistently lower blood levels.
psychiatric side-effects. However, other side-effects in a different way, by studies have found higher rates of monitoring the drug's psychological Some people clear efavirenz more depression in people taking efavirenz.
effects in a ‘blinded' study, in which the slowly than others due to a particular 303 participants did not know which genetic variation. This genetic variation Adding to the body of evidence against drugs they were taking. Again, the is common among people with a black the link between efavirenz and study's investigators saw no differences African heritage and it may increase the depression is a new study from France, in the levels of anxiety or depression risk of efavirenz-related side-effects.
published in June. This study examined between the 200 participants on Testing is not currently available to find the effects of switching 178 people efavirenz and the 103 not on efavirenz.
out who has this particular genetic from an anti-HIV treatment make-up. However, therapeutic drug combination that included a PI, to a "We provided a controlled, systematic monitoring may be used to identify combination that included efavirenz.
evaluation of efavirenz on anxiety and people who are being exposed to high The outcomes were compared with 177 depression and found no evidence that concentrations of efavirenz.

aids treatment update july 2006 In the 25 years since what is now these discrimination issues early on by and it is now their strategy to involve known as AIDS was first described in placing HIV testing within the free and primary care in sexual health and HIV a group of gay men in California and confidential GUM (genito-urinary services. The problem, however, is that New York, for many people living in medicine, or sexual health) clinic.
most GPs are not adequately developed nations like the United When it became available, HIV experienced or skilled in complementing Kingdom, an HIV diagnosis has treatment was provided in these sexual health and HIV specialist care.
evolved from a death sentence into a GUM clinics and other specialties, complex chronic condition.
Nevertheless, some of our healthcare like Infectious Diseases, became needs – including general care for involved, and, therefore, many doctors Constantly-evolving monitoring and non-HIV related conditions and care treatment are not the only reasons why in general practice (GPs, who provide relating to HIV that sits naturally in HIV is a complex disease. Since HIV is primary care) had limited exposure to general practice (e.g. facilitating also primarily a sexually transmissable patients with HIV.
referral to mental health services in the condition and is also an unfolding global In the 21st century, however, it is clear community) – may be better managed event – with legal, social and political that both GUM clinics and HIV at a GP's surgery rather than at an implications – it is further complicated specialist services are struggling to HIV clinic. And there may be new roles by prejudice, stigma and discrimination.
meet demand. The government believes for HIV-educated GPs to play in the The UK's National Health Service that the obvious place to relieve some future (e.g. the routine monitoring of (NHS) attempted to deal with some of of this pressure is in general practice, CD4 counts and viral load).

aids treatment update july 2006 Why do we need a GP? the British HIV Association (BHIVA), or have only mild symptoms of HIV at the symposium. "Therefore GPs are infection. And for people with advanced Until now, many HIV-positive people going to have to be involved, and that HIV disease, GPs are invaluable in have been able to use their HIV clinic means we need to make sure all of our helping to provide home support in not just for HIV care, but also for patients have GPs [by then]".
association with specialist community general health issues. Many clinics care teams and nurses.
currently provide prescriptions for There is absolutely no possibility, things that are definitely not HIV- however, that GPs will take over all William Ford-Young, who describes related (like flu vaccines, or asthma HIV care - at least for the foreseeable himself as "a pragmatic 'coal-face' GP, medicine) although some are beginning future. "I think we're a long away from with an interest in the GP's role in HIV to limit their prescribing to anti-HIV GPs routinely prescribing management and support" is one of antiretroviral therapy," Martin Fisher, two GPs on the government's HIV consultant at Brighton and Independent Advisory Group on Sexual Whatever the situation in your clinic Sussex University Hospital, told the Health & HIV, and is also Chair of the (and London HIV clinics are already NAM symposium. "Maybe in ten years Royal College of General Practitioners under pressure to save money this year but not in the next few years." (RCGP) Task Group for Sex, Drugs & due to only a 5% increase in funding HIV. He argues that all HIV-positive despite at least a 10% increase in And Judy Hague, HIV programme people can really benefit from having a patients) their prescribing policies will director of the London Specialised GP, regardless of the kind of care they probably have to change in 2008.
Commissioning Group confirmed that receive at their local HIV clinic.
That's when a new NHS funding "the case for HIV remaining a system known as payment by results specialised service is a strong one.
"My feeling, as a GP, is that GPs have promises to radically alter how People with HIV may have other tremendous skill and experience and a HIV-positive patients get services, and health problems, and will require whole team at their fingertips to how HIV outpatient clinics get paid for access to a balance of services provide ongoing care for people with providing them (for more on this see [including GPs] but I don't personally chronic conditions," he says. "Certainly, Does cost matter? in ATU 150; anticipate that HIV care will move people need a specialist for the October 2005).
outside of specialised services [i.e. the complicated HIV issues like HIV clinic]".
In May, NAM held a one-day clinical symposium to discuss issues around the What can GPs do for us? future of HIV treatment. Part of the There are several reasons why afternoon session focused on accessing registering with a GP and telling them care in the context of NHS overspends, of your HIV status may be beneficial.
cost-cutting and payment by results; The GP's surgery should be more how increasing HIV diagnoses are accessible and may be open in the overburdening already stretched HIV evening for appointments. Unlike clinics (which provide secondary care); HIV physicians, GPs can visit you and how GPs can be better integrated at home and you can also access into the care of HIV-positive people.
a doctor for emergency visits after hours via your GP. They "With payment by results we will no are an alternative to the longer be able to act as GPs and refer specialist clinics for sorting out our patients to another specialty, for and treating general problems for example to get a hip replacement," people who are largely asymptomatic noted Dr Margaret Johnson, Chair of why GPs need to be integrated into hiv-positive care by Edwin J Bernard

aids treatment update july 2006 therapeutics, virology and immunology.
sufficient knowledge [about HIV]. We clinic, and presented to the BHIVA But I think GPs are good at doing have to get over these barriers and Conference this March, found that 85 things that HIV specialists possibly make sure GPs get involved." out of 1687 patients (5%) had aren't good at; we can manage many of experienced HIV-related discrimination Understandably, this is causing a lot of the things that go hand-in-hand with from their GP in the past[1]; gay men anxiety, not just amongst HIV-positive chronic disease: the psycho-social were much more likely to have people and the community groups that issues; the relationship difficulties; the experienced this discrimination than advocate for and support them, but also mental health-related things, like African men and women.
amongst many GPs and HIV physicians.
depression; and the way that a chronic Since December 2005, the Disability disease can generally affect your So far, however, no clear policy has Discrimination Act has protected feeling of well-being. These are things emerged regarding who will lead this that good GPs deal with all the time." anyone diagnosed HIV-positive from integration of GPs into HIV-positive being discriminated against in a people's care. For example, neither the Steven Ash, HIV consultant at Ealing healthcare setting, since they are DoH, nor the NHS, nor many of the Hospital, in west London, agrees that providing services (one of the areas leading bodies involved in either "there are some problems patients may covered under the Act). It is, therefore, specialist HIV care or general practice have that are better dealt with by a unlawful for GPs not to provide the - including the RCGP, BHIVA, the GP, and patients miss out if they do not same services to an HIV-positive make use of a GP service." British Association of Sexual Health person that they provide to and HIV (BASHH) and the British HIV-negative people, or to discriminate Barriers to integration Medical Association (BMA) - have in the standard of service or the terms "It comes down to the right patient agreed on how best to educate GPs on which the service is provided.
seeing the right doctor for the right thing," said Martin Fisher at the NAM However, the law cannot change symposium, but he added that "there attitudes overnight, and there still does are a lot of barriers" to the integration We are now in the unfortunate appear to be a lot of concern from of HIV into primary care. "Some of situation where the people who have HIV-positive people over another, related those barriers are with the GPs, who lived with HIV for the longest time issue: a perceived lack of confidentiality, are scared about HIV," he said. "Then have the least trust in GPs. This is particularly around informing third there are problems with secondary likely because most of the people parties - e.g. employers, insurance care. I think we're a bit too precious initially affected by HIV in the companies - about their HIV status. This and not very good at letting go, and I UK - gay men, injecting drug users and continues to be a common reason given think we need to. And then I think sex workers, all of whom were by HIV-positive people for not involving there are barriers around patients marginalised from society - often being scared of their GPs having experienced prejudice, stigma and discrimination from their GPs during For example, Ealing's Steven Ash tells the Thatcherite 1980s and early 1990s.
ATU that "around 10% of our patients have no GP. Another 30% do In fact, a survey undertaken last year not allow us to communicate with at a north-east London HIV outpatient their GP, and the GP is therefore unaware of their diagnosis." William Ford-Young says that although in the past he's heard some horror stories about issues such as a lack of respect for confidentiality, things have much improved. And where they haven't, "it's important that patients, and patients' organisations, challenge wherever they are finding bad practice." Better communication needed"HIV remains the only condition whereby you can go from your diagnosis to your death without your GP ever

aids treatment update july 2006 knowing about it," notes Dr Ford-Young.
through no fault of their own," he told expecting GPs to provide HIV care," "In this day and age, that's appalling." the NAM symposium.
explains Martin Fisher, "we're expecting the GPs to provide the primary care for One of the problems is that the 1974 Enhancing services people who also happen to have HIV." Venereal Disease Regulations - which Happily, many individuals and provide for strict confidentiality within organisations are beginning to work Education is the solution the GUM clinic - may be preventing together to try to find solutions to Surinder Singh, a south-east London good and clear communication these problems.
GP with a special interest in HIV, and between HIV clinicians and GPs and the second GP on the government's we, as patients, are often caught in The Medical Foundation for AIDS and Independent Advisory Group on Sexual the crossfire.
Sexual Health (MedFASH) - a charity Health & HIV, noted at the NAM supported by the BMA - recommended symposium there is "great variability At the moment, HIV physicians can that all people with HIV should have with where locally enhanced services only keep a patient's GP informed of access to good quality GP care are available." medication and other important encompassing prevention, diagnosis, treatment information if the patient treatment and care as part of their These services are funded by individual gives them permission to do so.
'Recommended standards for NHS PCTs and, thanks to the government's However, the simple act of asking for HIV Services', published in October decentralised funding of NHS services, permission may create unnecessary 2003 and endorsed by the Department funding decisions are left to the anxiety, and suggests that there is of Health (DoH). A year later, they discretion of these PCTs. "So in south something inherently wrong in the GP produced an excellent booklet, HIV in east London we don't have any," having this information. Like any successful relationship, good communication can remove uncertainty, mistrust and fear.
Dr Ford-Young's RCGP Task Group has been trying to improve communications between GPs and HIV physicians for several years. "I think the waters have got very muddied with secondary care primary care, aimed at educating providing a primary care service for a GPs about myriad HIV issues - from continues Dr Singh, lot of HIV-positive patients," he says.
HIV tests to drug-drug interactions.
"and that doesn't seem all that "To help remedy that, we are working equitable. The patient should on processes of safe communication, Later this month, BHIVA is hosting a safe prescribing, and sorting out who's one-day workshop comprising many responsible for doing what," he says.
HIV professionals, representatives from Dr Ford-Young agrees, but argues that "We're working quite hard to make the DoH and Primary Care Trusts HIV-positive people don't necessarily sure that HIV-positive people can have (PCTs), and many patient advocate need a locally enhanced service to get good GPs, but obviously this only works organisations, including NAM. Focusing the best from their GP. "The bottom well if GPs are aware of their patient's primarily on how best to improve line is that if you have a good quality HIV status." access to HIV care throughout the UK, general practice - and that's not just it will also include a discussion of how the GP, but the whole team - things Brighton's Martin Fisher agrees GPs can best be integrated into the work well for patients with HIV no communication must improve - not just care of HIV-positive people.
matter who they are or how they've between GPs and HIV physicians, but acquired their HIV infection. And those also between HIV-positive people and And in several areas of the country, issues shouldn't have to arise because GPs. "It's important to have that GPs are being educated about HIV at GPs should be good for everybody.
dialogue with GPs because if we don't locally-run workshops. In Brighton, involve them, and if the patient doesn't they've been running an interactive "I know that that's an ideal, and it's tell them, they're not going to know two-day HIV education course for important to recognise that there are what medications we've prescribed and interested GPs and their practice gaps between the ideal and reality. But that could lead to GPs prescribing nurses since 2004, resulting in at least educating GPs about HIV, educating drugs that interact, or change a drug eight GP practices in Brighton and patients about GPs, and creating a we've prescribed, like a statin [lipid- Hove providing what is known as much better dialogue between the lowering drugs, many of which can locally enhanced services for specialists and general practitioners interact with anti-HIV medicines], HIV-positive people. "We're not can close that gap."

aids treatment update july 2006 Why HIV-positive people need special consideration when it comes to vaccinations, by Edwin J Bernard After more than a year in the making, themost comprehensive immunisationguidelines ever produced for HIV-positiveadults are now available to download foran extended consultation period from theBritish HIV Association website[1]. Theywill be revised based on feedback receivedby mid-September, and the final guidelineswill then be published in HIV Medicine. Compared with our HIV-negative counterparts, HIV-positive people may have an increased risk of infection, or experience more severe disease, following exposure to vaccine-preventable diseases.
The guidelines cover in detail how the risk of acquiring more than twenty infectious diseases - from anthrax to varicella zoster - can be substantially reduced in HIV-positive individuals via vaccination, some prior to, others after, exposure. In addition, the guidelines address the use of passive immunisation after exposure to infectious diseases such as measles or chicken pox.
The writing committee - which included virologists, microbiologists, infectious disease and HIV physicians, public health specialists, and epidemiologists - was headed by Dr Anna Maria Geretti, consultant virologist at London's Royal Free Hospital.
Here, she explains why the guidelines took so long to produce, provides an overview of the most important - and controversial - issues, and discusses some practical considerations, including who will pay for and provide the various vaccines.
aids treatment update july 2006 Why the need for such Now that people are living longer, and for immunisation following exposure to are often very well for extended periods rabies. And then there are some areas We realised that some important of time, they need to be protected in which are controversial and for which it issues needed addressing. Recently, the long term from infections that were took a long time for the committee to the Department of Health (DoH) perhaps less of a concern previously.
achieve consensus. In fact, in some areas revised the UK immunisation For example, HIV-positive people now the recommendations remain tentative, guidelines for the general often wish to travel to countries with a which is why we are keen to receive population[2], and although they high risk of infections. Some people feedback during the consultation period.
mention HIV frequently, the also want to access jobs that may For example, the benefits of recommendations are not very carry a risk of exposure and therefore pneumococcus vaccination remain really specific. The DoH had also consulted require protection. An additional with BHIVA about the possible use of consideration is that a significant the smallpox vaccine while developing proportion of HIV-positive people may Pneumococcus is responsible for plans for dealing with a potential have migrated to the UK in adult life much of the bacterial pneumonia bioterrorist attack. Since this is a live and perhaps missed vaccinations that seen in HIV-positive people, and can vaccine that is contraindicated in cause other illness, like meningitis.
are part of the routine childhood HIV-positive people, they wanted to A study from Uganda[3] raised schedule. The DoH has issued know what we thought about doubts about its safety and recommendations about ensuring effectiveness, but other studies mandatory HIV testing for people adequate vaccine coverage in these contradict this. How did you reach who had been identified as needing populations and HIV-positive people the vaccine (i.e. front-line should not be excluded if vaccination With great difficulty! We had a can be given safely. These were some of prolonged discussion where all the the factors that prompted us to So, those were the starting points that available evidence was discussed, and develop the guidelines.
made us think about immunisation in we examined the pros and cons. In the general. We were also aware that end we thought that the findings from Your first presentation on the potent anti-HIV therapy has changed Uganda would not necessarily apply to guidelines was at the BHIVA the natural history of HIV infection.
meeting in Dublin in March 2005.
the UK, where most people who have a First of all, improved immunity through They were supposed to be made low CD4 count would be started on antiretroviral therapy means that the available later that year. What made anti-HIV therapy, thereby reducing the overall efficacy of vaccination is now it such a long and difficult process? risk of pneumonia seen with the greatly improved in HIV-positive The lack of controlled data, both in vaccine recipients in Uganda. However, people. Another important terms of susceptibility to infection and although the vaccine may be beneficial consideration is that improved also how really effective these vaccines in the UK, there are no well-controlled immunity means that some vaccines are in someone who has regained CD4 data to back this up and most of the that were previously contraindicated cells after starting anti-HIV therapy. For evidence for a beneficial effect comes because of safety concern (e.g. yellow example, there are no good controlled from small studies. That's why it has fever, or the MMR - data to determine the need for hepatitis been so difficult to actually achieve a measles/mumps/rubella - vaccine) B boosters after successful vaccination, consensus. We do recommend the should now be reconsidered.
or for deciding on the optimal schedule vaccine for HIV-positive people with a aids treatment update july 2006 CD4 count above 200 cells/mm3 on Preventing rabies is a classical stable anti-HIV therapy. However, the example of an infectious disease that risk of pneumococcal disease is higher ought to be dealt with differently in in people with CD4 counts below 200 HIV-positive people. Our patients are cells/mm3 who are not on anti-HIV travelling more and more, and many therapy which is why we say that are travelling to countries where rabies vaccination may be considered for HIV- is still endemic - India, Pakistan, infected persons with CD4 count below Thailand, Vietnam. However, because 200 cells/mm3.
post-exposure prophylaxis for rabies needs to be done differently compared Since it is a live vaccine, the oral to HIV-negative people - you may have polio vaccine (OPV) is listed as one to use more doses of the vaccine and not recommended for HIV-positive test for antibody responses more people, especially since it has been frequently - it makes sense to discontinued in the UK. Why, then, is recommend a preventative vaccine. In it discussed in the guidelines? fact, the rabies guidelines have taken a Yes, it has been discontinued, so that long time to write because they are so is not a problem for those of us in the complicated, and there's very limited UK. But it may be a problem for evidence to inform them. Along the someone who travels, or who may same lines, a traveller with HIV may come into contact with someone from want to consider a typhoid vaccine, and those countries where it continues to if in doubt about the risk, it may be be used who may be shedding the better to take the vaccine than not.
vaccine. So it's an indirect problem. In addition some people from You mentioned earlier that the sub-Saharan Africa - where it is still DoH consulted with BHIVA on the being used - may come into contact smallpox vaccine.
with this vaccine, and may even be What recommendations did you considering getting the vaccine if they go back home. It's important for us to At the moment the only people receiving say that it should not be used in the smallpox vaccine are those who have HIV-positive people and give guidance been identified in the UK to be the on the management of people who first-line response team in case of a may come in contact with someone bioterrorist attack. We felt that there shedding the vaccine.
had to be some guidance in case an HIV-positive person is asked to be part Travel-related risks are covered of that particular front-line team, or if extensively in the guidelines. Rabies, the hypothetical scenario of a for example, is dealt with somewhatcontroversially: bioterrorist attack becomes real. We say you recommend that HIV-positive that if someone has a real risk of people travelling to high-risk areas exposure to smallpox, then they should receive a preventative rabies vaccine be given the vaccine. However, if the risk before they travel. Isn't this very is only hypothetical, we recommend different to what is recommended against the vaccine because it's a very for HIV-negative people? poorly tolerated vaccine with a lot of Overall the recommendations for travel side-effects. It can be nasty even in are the same as for HIV-negative people who are HIV-negative and it people. However, one should keep in would never get approval for use mind that for some HIV-positive people nowadays! However, if there was a the risk of infection and the bioterrorist attack and there was a real consequences of being infected may be risk for HIV-infected patients, then we more significant. Furthermore, responses would recommend the vaccine, as the to post-exposure immunisation may be risk of vaccination would be less than the suboptimal. These considerations risk associated with the infection itself.
indicate that, provided the vaccine is safe, one should have a lower threshold Measles is relevant to many people for recommending vaccination.
right now. Recent outbreaks have aids treatment update july 2006 been reported in the UK, and it There are tests that we have for certain However, I think we need to involve can cause serious illness in people infections, like measles or polio, but not GPs more and more in the care of our with HIV. Given that the live for all. Therefore in the absence of a HIV-positive patients and this is measles vaccine itself may cause reliable history of vaccination it seems certainly very important for addressing illness in people with HIV, what do preferable to consider vaccination, as the issue of vaccinations. I have no recommended in the DoH guidelines for illusions that just by being registered Measles in HIV-infected patients with the general population.
with a GP and issuing a set of poor immunity is a devastating guidelines all recommended infection. It can cause encephalitis Who should shoulder the immunisations would automatically be (swelling of the brain) and pneumonia, responsibility for investigating given, because unfortunately we have and has a high mortality rate. Given vaccination histories and providing examples from other areas of care the current outbreak situation we where things don't always happen as definitely must make an effort now to I think that patients should take some they're supposed to in this field.
check that our patients are immune, responsibility for keeping track of their Certainly, as HIV physicians, we should and - provided the CD4 count is above vaccine records but HIV clinics should liaise closely with the GPs and should 200 and the person is well - we should actually take the lead position over also place responsibility on our give immunisation if they are not these vaccinations. The ideal situation patients for taking good care of their immune. We are recommending in the is that we assess the need for health. Through this partnership it is guidelines that if someone has no prior immunisation through the HIV clinics possible to ensure that the history of vaccination, or infection with because it's easier to control and recommended vaccination courses are measles, then they should be screened monitor, and reliable information on started and completed appropriately.
by doing a test - the measles IgG test - clinical history and immune status is and if found to be negative they should available. The HIV clinics should run What about travel-related vaccines? be offered the vaccine. The same all the necessary tests if indicated and I think that who pays for and applies for other childhood vaccines: make the necessary recommendations, administers travel-related vaccines is a polio, diphtheria, tetanus. If you were but they should then enlist the help of different issue. It's probably more born in the UK after 1962 you were GPs whenever possible to actually realistic to think that HIV-positive probably vaccinated against these administer the sort of vaccines that are people will need to meet the cost if the infections as a child. However, if you routinely available through the NHS.
vaccine is needed for travel just as were born before that, or outside of the people without HIV have to pay for All HIV-positive people don't have UK at any time, you might actually not these vaccines. If we are making the GPs, and many of those that have have a completed vaccination history argument that HIV-positive people are one are not comfortable disclosing and may benefit from a new vaccine their HIV status to them. It is not well enough to travel to high-risk always going to be possible for an areas, and that they can have HIV clinic to refer someone to previously contraindicated vaccines How you do determine whether their GP to provide, for example, because their immunity is okay, I can't you've been vaccinated against the MMR jab.
really see us being in a very strong infectious diseases in the past if position to argue that if someone you can't remember and/or there That was also a difficult dilemma for decides that they want to travel and us when writing the guidelines.
they need a vaccine, that they should be entitled to have it for free based on their HIV status.
further information Please address questions and The BHIVA immunisation guidelines are for HIV-positive adults over the age of 16. The Children's HIV Association (CHIVA) produce children and adolescents, available at aids treatment update july 2006 Serious heartcondition still affecting Switch from triple nukes, even if you're doing well An expert in pulmonary arterial hypertension (PAH) - a relatively rare, but very serious, complication of HIV infection - is advising An Italian study has found that people starting treatment any HIV-positive individual who is feeling breathless for no for the first time who take a triple nucleoside reverse apparent reason to see their doctor to investigate whether PAH is transcriptase inhibitor (NRTI) combination with abacavir (Ziagen) as their third drug are significantly more likely toexperience a rebound in their viral load - even if they had Pulmonary arterial hypertension causes blood pressure to rise in achieved durable suppression of HIV - than those who the arteries that carry oxygen-deprived blood away from the heart take the non-nucleoside reverse transcriptase inhibitor so that it can be replenished in the lungs. Incidence in the general (NNRTI) efavirenz (Sustiva) as their third drug.
population is just one or two cases per million. Before potent Current treatment guidelines say that a triple NRTI anti-HIV therapy was available, it was estimated to be about regimen - usually Trizivir which contains AZT, 3TC and one-in-200 in people with HIV.
abacavir in one pill - should only be considered as a Now, new research from France has found that PAH is no less starting regimen in very occasional circumstances, for common today than it was ten years ago. Last year, 7,648 HIV example when TB medicine is also needed (since there are patients from 14 centres across France were screened for PAH. Of interactions with most other anti-HIV drug combinations) 739 found to be suffering from breathlessness - the most common or when one pill once a day will make a significant early sign of PAH - thirty-five were found to have PAH after further difference to treatment adherence. This is because several investigation: an incidence rate of almost one-in-200.
studies have found that triple NRTIs are not as potent as combining two NRTIs with another class of drugs.
Lead author Dr Olivier Sitbon told the American Thoracic Society International Conference, held in San Diego in May, that doctors The Italian study wanted to see if patients who took should have a low threshold for suspecting PAH if their patient abacavir as a third drug, and who had initially achieved an undetectable viral load, had an increased risk of experiencing subsequent virological failure compared to It is currently unknown why HIV can cause the pulmonary arteries individuals taking efavirenz-based therapy. They observed to become thickened and narrowed, leading to PAH. In addition, 744 patients who were starting anti-HIV therapy for the PAH is seen in all groups of people with HIV infection, irrespective first time and found that those who took abacavir as their of the cause of infection or CD4 count. It is also a much more third drug had an 85% greater risk of rebound than those serious disease in HIV infection, and according to a Spanish study who received efavirenz.
published in 2003, just over half of the individuals who developed the condition died within three years.
Consequently, they recommend that people taking an abacavir-containing triple NRTI combination should New treatments for HIV-positive people with PAH are currently change to a more potent anti-HIV regimen, even if they being investigated, the most promising of which may be bosentan have an undetectable viral load.
(Tracleer). This oral drug works by blocking the action of endothelin,a hormone which occurs in higher levels in people with PAH.
If only NRTIs can be used, however (due to TB drug Although there was initial concern that bosentan may damage the interactions, for example), current guidelines suggest that one livers of HIV-positive people, new research in people taking the drug possible option would be to add a fourth NRTI - tenofovir for two years suggests that this is not necessary the case.
(Viread) - to Trizivir.
LGV continues to spread amongst HIV-positive gay men Almost 350 cases of the sexually transmitted infection (STI) lymphogranuloma venereum (LGV) - a form of chlamydia usually affecting the rectum - have now been diagnosed in the United Kingdom. Nearly all of the cases involved gay men, more than 75% of whom were HIV-positive. Coinfection with other sexually transmitted infections is being seen at the same time: one-in-four had another STI, and hepatitis C virus coinfection was seen in one-in-ten.
Epidemiological evidence suggests that LGV is transmitted via unprotected anal sex and fisting, which may also be the way the hepatitis C is being transmitted sexually; again this is primarily affecting HIV-positive gay men.
Men who have sex with multiple partners at sex parties and sex clubs appear to be most likely to be diagnosed with LGV; 71% of the men diagnosed so far reported this risk factor. LGV has now been seen in all parts of the UK, although most of the cases are being diagnosed in London and Brighton: the Kobler Centre at the Chelsea and Westminster Hospital in London is reportedly diagnosing ten new cases of LGV infection a week.
LGV can cause very unpleasant symptoms, similar to other bowel disorders, and may not be correctly diagnosed at first. In the current outbreak, the commonest symptom has been proctitis - pain and inflammation in the anus and rectum. In some cases this has been accompanied by swollen glands in the groin, and often by a discharge of mucus from the rectum (which can be bloody), and constipation.
Condoms and latex gloves are very effective at preventing the transmission of STIs, including LGV, and, once correctly diagnosed, the infection can be cured using a 21-day course of the oral antibiotic doxycycline.
Anti-HIV therapy adds thirteen years to post-AIDS survival American researchers have calculated that today's highly effective anti-HIV treatments have added 160 months (thirteen years andfour months) to a person's life expectancy once they have been diagnosed with AIDS.
Using a computer model to determine the effect six periods of anti-HIV treatment had on the survival of people with HIV after an AIDSdiagnosis, they found that post-AIDS survival increased from 19 months prior to 1996 to 179 months - almost fifteen years - after 2003.
"This survival benefit greatly exceeds that achieved for patients with many other chronic diseases in the United States," they say.
better practice [page four] news in brief [page twelve] Society International Conference, San Serious heart condition still affecting Diego, abstract A728, 2006.
inhibitors in patients with initially 1. Elford J et al. Discrimination LGV continues to spread amongst suppressed viral loads. J Infect Dis experienced by people living with HIV-positive gay men 194 (online edition), 2006.
HIV. HIV Med 7 (supplement 1), 1. Sitbon O et al. Prevalence of 1. Ward H et al. Lymphogranuloma Anti-HIV therapy adds thirteen years to abstract P93, 2006.
pulmonary arterial hypertension in post-AIDS survival HIV positive outpatients in the venereum (LGV) in the UK: national immunisation guidelines [page eight] Highly Active Antiretroviral Therapy surveillance of a re-emerging disease.
1. Vermund SH. Millions of life-years Era. American Thoracic Society National Sexually Transmitted Disease saved with potent antiretroviral drugs International Conference, San Diego, Prevention Conference, Jacksonville, in the United States: a celebration, with abstract 807, 2006.
late breaker, 2006.
challenges. J Infect Dis 194: 1-5, Switch from triple nukes, even if you're 3. French N et al. 23-valent 2. Humbert, MD et al. Safety profile of pneumococcal polysaccharide vaccine bosentan in patients with pulmonary in HIV-1 infected Ugandan adults: arterial hypertension related to HIV: 1. Cozzie-Lepri, A et al. A comparison double-blind, randomised and placebo long-term results from the Tracleer between abacavir and efavirenz as the controlled trial. The Lancet 355: PMS database. American Thoracic third drug used in combination with a 2106-2111, 2000.
background therapy regimen of 2 aids treatment update july 2006 primary care at hiv clinics are HIV clinics providing GP services? wonders Edwin J Bernard In our lead article, Better Practice, it was argued that the integration of GPsinto caring for HIV-positive people is inevitable. NAM has been hearing froma lot of concerned HIV-positive people regarding this move. Since each HIVclinic has its own policies we thought we'd try and find out ourselves what ishappening. It hasn't been easy. In May, we emailed a snapshot survey to seventeen HIV clinics across the country. We received six responses at press time - four from clinics in London, one from Manchester and one from Edinburgh.
Although their responses may not reflect what is happening at your HIV clinic, the different policies and attitudes make for Do you have a policy regarding your patients having GPs? Central Middlesex Hospital, London: We encourage our patients to see aGP, or get registered with one.
Ealing Hospital, London: We try to provide a "holistic service" andtherefore end up treating many non-HIV-related conditions. This isparticularly so for the 40% of our patients who either don't have a GP ordo not allow us to contact their GP. We will resist any policy to changethis.
Queen Mary's Hospital, London: We have an ethos rather than a policy.
We encourage patients to have a GP and see their GP for non HIV-relatedcare.
further information Mortimer Market Centre, London: Our policy is to advise all patients to To find out more about the Patient have a GP for all the usual reasons. We keep to General Medical Council Advice and Liaison Service (PALS), [GMC] guidance on confidentiality and communication.
which provides information on the NHS North Manchester General Hospital: We have no policy as such, but we do and health related matters and encourage all patients to register with a GP and endeavour to find them confidential assistance in resolving one if they are not registered.
problems and concerns quickly, contact your local PCT or NHS Direct on Western General Hospital, Edinburgh: We have no written policy. We do not see patients for non HIV-related care outside their routine HIVappointments. If patients pitch up without an appointment, they are For more on the GMC's confidentiality directed to acute receiving; if their problem is HIV related, they will be aids treatment update july 2006 Do you have a policy regarding providing prescriptions for drugs that are not antiretrovirals, but may berequired due to HIV infection (e.g. lipid-lowering drugs, diabetes meds, antidepressants etc.)? Central Middlesex Hospital: Yes. We are generally happy to prescribe these, except now that home delivery has started, prescribing these drugs is more difficult. We will have to ask GPs to do more in the future.
Ealing Hospital: We prescribe everything on our hospital formulary through our HIV pharmacy annex. Prescriptions are, therefore, free. This includes all the drugs you've listed as well as vaccines, malaria prophylaxis, etc.
Queen Mary's Hospital: We encourage people to be prescribed medication by the service which manages them. For example, we don't manage their diabetes or increased lipids, so wouldn't prescribe those medicines, but we have policies on when to refer on, where problems are related to HIV.
Mortimer Market Centre: Our clinic guide advises that patients should be encouraged to consult their GP for non HIV-relatedissues. If there is no GP or we have no consent for GP communication then we will prescribe for certain non HIV-relatedproblems, though we advise patients that the GP may be the most appropriate person to be doing the prescribing.
North Manchester General Hospital: As long as their antiretrovirals are also on the prescriptions, or the patient is known to beon antiretrovirals, then these kind of drugs are issued. We try to persuade patients to get GPs and eventually for them to takeover the care of and prescribing for non HIV-related conditions - but with backup phone numbers for discussions aboutinteractions etc.
Western General Hospital: We used to provide these meds via our hospital pharmacy but our pharmacy dispensing service isstretched and cannot cope. At our discretion, however, we would squeeze a non HIV prescription in, if the patient cannot get totheir GP.
Do you maintain a referral list ofHIV-friendly GPs, HIV-educated How are you helping patients who cannot access a local GPs, or GPs providing a locally GP they trust and/or do not wish to disclose their HIV enhanced service in your area? status to their GP? Central Middlesex Hospital: We used Central Middlesex Hospital: We would prescribe for them, but to, but not now really. There are no our community workers will help them find GPs if possible.
local GPs who we think are specificallyHIV-unfriendly.
Ealing Hospital: We encourage patients to register and use a GP. We do our best to make up for the lack of a GP if Ealing Hospital: We know of GPs in they do not wish to have or use a GP.
the area who we think are good,knowledgeable and non-judgemental.
Queen Mary's Hospital: If patients don't wish to disclose Many years ago we ran a project with their status to a GP, we discuss this with them and challenge Hammersmith Hospital to help care their beliefs regarding confidentiality. Where there is a genuine for people with HIV, and thus had a concern - for example, their neighbour works at the GP's practice "special" liaison with some GP's in - we would help them find a different GP, and occasionally people have changed their GP to enable them to discuss their HIV.
Queen Mary's Hospital: We have a Mortimer Market Centre: If patients can't find a suitable GP then we community clinical nurse specialist to tell them to contact the Patient Advice and Liaison Service (PALS) assist with this. She knows which GPs or NHS Direct and we provide the telephone number. We utilise the have other HIV-positive patients, which NHS website to give information on their nearest GP surgery. If they reassures people who have concerns do not trust their GP then we discuss the reasons behind this and at about confidentiality which are more the end of the day must respect the patient's wish for confidentiality to do with their fear than reality.
as per GMC long as the patient is making an informeddecision, then we respect this.
Mortimer Market Centre: No.
North Manchester General Hospital: We take over the prescribing North Manchester General Hospital: and, where possible, try and find the patient a ‘good' GP in their area.
Western General Hospital: Almost all of our patients have a GP who Western General Hospital: Our would provide primary care. If there is a problem, they are helped to Edinburgh GPs are usually very helpful choose another GP or use A&E services.
and we very rarely have problems. Weare lucky.
thanks to our funders NAM's treatments information for people living with HIV is provided free thanks to the generosity of: Abbott Laboratories International & UK; Access 4; Ajahma Charitable Trust; Alan & Nesta Ferguson Charitable Settlement; Avexa; Birmingham PCT; The Body Shop Foundation; Boehringer Ingelheim International & UK; Bolton PCT; Bristol-Myers Squibb UK HIV & Hepatitis; British HIV Association (BHIVA); Cleopatra Trust; Corkery Group; Crusaid; Derek Butler Trust; Diana, Princess of Wales Memorial Fund; Government of the United Kingdom, Department of Health; East Sussex, Brighton & Hove area PCTs; The Elton John AIDS Foundation; Gilead International & UK; GlaxoSmithKline UK; Healthsure Charitable Trust; Hugh Fraser Foundation; International HIV/ AIDS Alliance; Janssen-Cilag; Lloyds updated edition - july 2006 TSB Foundation for England and Wales; Lloyds TSB Foundation for Northern Ireland; London HIV & GUM Commissioning Consortium; MAC AIDS Fund; Merck Sharp & Dohme UK & International; Newcastle PCT; Whether recently diagnosed, Norfolk PCT; Manchester city area PCTs; Miss Agnes H it's absolutely great; Hunter's Trust; Merton Social Services; Peter Moores thinking about starting or Foundation; Pfizer UK & International; Positive Action so practical and easy changing treatment or have (GSK); Roche Products UK Hep C; Roche Products International & UK; The Russell Trust; Salford PCT; Shire lived with HIV for a long personal stories really Pharmaceuticals; South East Essex PCTs; South West time, NAM's book Living bring everything to Essex PCTs; St. Stephen's AIDS Trust; Stockport Social with HIV provides answers Services; Thomas Sivewright Catto Charitable Settlement; life. I am finding useful Tibotec; Virco; West Sussex PCTs; Worcestershire PCT to the questions you might information that I find yourself asking.
never knew and I can't NAM would also like to acknowledge the generous support of individual donors, and in particular Gavin Hay believe that it is free! Where to find out more about HIV Find out more about HIV treatment: This book is free to people NAM's factsheets, booklets, directories and personally affected by HIV, website, keep you up to date about key there is a charge for topics, and are designed to help you make your healthcare and HIV treatmentdecisions. Contact NAM to find out more Order your copy today by phoning, and order your copies.
emailing NAM or filling the order formbelow and returning it to the freepost Information events in London address listed.
On the last Monday of every month, an expertspeaker discusses an HIV treatment relatedtopic. Entry is free. The next topic is‘Feedback from the International AIDS Please use this order form to get your FREE copy of Living With HIV Conference, Toronto', and will be held on 21st If you are a professional, please contact NAM directly. Contact details are shown below August 2006. For more details, go
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Micro-Level Value Creation Under Managerial Short-termism ∗ Jonathan B. Cohn† University of Texas at Austin University of Texas at Dallas Wharton Research Data Services We present evidence that managers facing short-termist incentives set a lower threshold for accepting projects. Using novel data on new client and product an- nouncements in both the U.S. and international markets, we find that the marketresponds less positively to a new project announcement when the firm's managers haveincentives to focus on short-term stock price performance. Furthermore, textual analy-sis of project announcements show that firms with short-termist CEOs use more vagueand generically positive language when introducing new projects to the marketplace.Keywords: CEO Short-termism, Corporate Investment, CEO Compensation, CareerConcerns, Corporate Governance

__— introduction —

MODULE PSYCHIATRIE (PSYCHOPATHOLOGIE) Dr Pierrette ESTINGOY _ (1er semestre 2008-2009) I ntroduction : généralités Introduction historique à la Psychiatrie. Approche clinique en psychiatrie A. Les grandes catégories de troubles psychiatriquesB. Entretien psychiatrique et démarche diagnostique en