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HIV outpatient services across the United Kingdom are seeing large increases in their patient workload. This is fuelled by the success of highly active antiretroviral therapy (HAART), resulting in fewer deaths, and by increases in the number of new diagnoses.1 A further rise is anticipated in England following implementation of “The national strategy for sexual health and HIV” that plans to increase HIV testing dramatically in order to reduce the number of undiagnosed HIV infections by 50% by the end of 2007.2 The success of HAART has also changed the focus of many doctor-patient outpatient consultations from prophylaxis and management of opportunistic infections, to issues related to the complexities of HAART, sexual behaviour risk reduction and promoting healthy lifestyles. As a result, HIV service providers need to develop new models of care that can deliver high quality, cost effective care to meet these changing demands. We reviewed the role of the doctor in providing routine outpatient HIV care.
Data were collected prospectively on all HIV infected patients attending for routine care between 24 June 2002 and 17 July 2002. We obtained complete data for 431 of 433 consecutive patient appointments. Of these, 79/431 (18%) did not attend their appointment. Of the remaining 352, the median age was 38 years (range 17–70), the majority were male (291, 83%), of white ethnicity (251, 71%) with a median CD4 count of 350×106/l (range 10–1390) and viral load (VL) of 600 copies/ml (range <50–1.2 million).
Consultants saw two thirds of attendees, specialist registrars a third. Almost half the consultations (173/352) were with patients who were defined by their physician as being asymptomatic with respect to their HIV infection; 66/173 (38%) of these were not taking HIV therapy and 107/173 (62%) were on HAART with a sustained virological response (VL<50 for >6 months). Over the next 8 months 53/66 (80%) of those not taking HAART and 68/107 (64%) taking HAART remained well with no significant changes to their health status. Of those on HAART, five required admission to hospital (bacterial pneumonia, three; cholecystitis, one; cryptococcal septicaemia, one), 12 made changes to their therapy (treatment interruption, four; virological rebound, three; toxicity, five) and 12 had intermittent low level viraemia (VL between 50 and 400). Other problems encountered in both groups included shingles (n = 7) and raised liver function tests (n = 11).
We have identified a high proportion of asymptomatic patients who are currently under regular review by medical staff and could potentially be managed by other healthcare professionals. Increased use of general practitioners and nurse practitioners are two potential options. We should review HIV outpatient service provision and move away from the “acute-terminal” model of care that has prevailed since the beginning of the epidemic and learn from chronic disease management models seen in other areas of the health service. As these new models are developed, in addition to staff requiring training to be conversant with common problems seen during routine monitoring of antiretroviral therapy, it is essential that evaluation is conducted to ensure similar levels of effectiveness, efficiency, and acceptability.
SE and DM developed the study; SE, SD, and CG collected and analysed the data; SD and KM wrote the text. SE, DM, and CG provided comments on the text.
Competing interests: None declared.