UK 2003 audit and national standards of care
Simon Collins, HIV i-Base
One of the most interesting sessions at the meeting was the summary from the 2002 treatment audit.
The audit is organised by BHIVA to evaluate the extent to which treatment guidelines are being followed in a wide range of 90 clinics across the UK – with current collective caseload of more than 21,000 patients. Participation in the audit is voluntary and is not compensated, and it is clear that clinic results will remain anonymous. Each clinic completes a summary from the most recent (25-50) case notes.
This year’s audit specifically focused on a survey of clinic practice and policies on starting treatment, follow-up of the 2001 audit, and arrangements for maternity care.
A rough breakdown of the participating clinics which provided regional and patient numbers is shown below:
|No of pts||London region||Outside London||Total|
Increased caseload in >95% clinics
Firstly, fewer than 5% of clinics outside London and no clinic inside London reported either a similar or reduced caseload. Importantly, more than 50% of clinics, both inside and outside London, reported an increase of over 15% in patient numbers.
Access to treatment and care when starting treatment
When asked about local policies on starting treatment, 74% of centres said their policy was to follow BHIVA guidelines. Thirteen per cent have local policy/guidelines that supplement BHIVA. Four percent have no local policy/guidelines and nine per cent did not answer.
When asked about policy on adherence (and one of the BHIVA recommendations is for hospitals to have a policy on adherence), 34% had local policy/guidelines on adherence, 58% did not and 8% did not answer.
Currently there is very little indication that there are restrictions on the choice of ARV drugs. Eighty-eight per cent of clinics had no restriction, only 2% have restrictions on cost and a further 2% have restrictions due to clinic policy. (8% of clinics did not answer).
Follow-up of patients starting treatment for the first time (based on physician reply rather than patient notes) showed that 63% of centres see a patient again after one or two weeks and 29% between two and four weeks. Only 2% of clinics wait for longer than four weeks and 6% did not answer. However first viral load after starting ART is only provided within four weeks by 39% of centres. Eighteen per cent wait until six weeks, 18% until seven to eight weeks and a disturbingly high 18% wait until 10 to 12 weeks. (9% did not answer).
An early (two to four weeks) initial viral load test, to at least confirm antiviral activity, has been included as common practice in many clinics for several years and will be strongly recommended in this year’s guidelines. It would be interesting to know whether an earlier revision of the guidelines could have improved this aspect of practice earlier.
Of 924 patients who started treatment for the first time, 56% were male and 44% female. Fifty-five per cent were Black-African and 36% white. Stated reasons for starting treatment included: disease progression (85%), prevention of vertical transmission (12%, and this was the sole reason for more than three-quarters of these patients), patient choice (9%), high viral load (29%) and recent seroconversion (3%).
Given the importance placed on starting treatment with a CD4 >200 cells/mm3 it is interesting to be able to look at the patterns for actual initiation of therapy. This audit showed that even among those with advanced disease, a significant minority of people starting treatment were not recently diagnosed. Ten per cent of those starting treatment at CD4 <50 and 20% of those starting treatment at CD4 50-100 had been diagnosed more than six months previously.
The audit was also able to highlight important pre-treatment testing, that should be integral to the effective use of HAART. It is noteworthy that 46% and 41% of clinics did measure blood pressure or serum lipids respectively. Although only 3% of clinics did not test for hepatitis B, 14% did not test for hepatitis C. Without these simple test results it is impossible to assess for cardiovascular risk or to monitor metabolic changes. Hepatitis status is essential prior to starting treatment for choice and dosing of individual drugs.
The figures for resistance testing may have been confused by methods of testing and storage, but the results are very disturbing for patient care. Only 6% of patients received resistance test results prior to starting treatment, with around 25% having a sample taken for storage. More than 50% clearly had neither a test nor sample stored. Given the minimal cost of storage and the importance of building a complete ‘resistance history’ by testing stored samples at future points of treatment failure, this is a very disappointing aspect of the audit.
Of the 25 patients for whom recent conversion was given as a reason for treatment and for whom the BHIVA guidelines clearly indicate the risk of infection with drug-resistant virus, only 16 were tested for resistance.
It is only possible to make general comments about the choices of combination therapy because a few confusing results cast doubts on the accuracy of recorded data. Although 65 different combinations were reported, 90% of patients were started on recommended combinations. With a backbone of two nucleosides, 60% used an NNRTI (with a 3:2 preference for efavirenz over nevirapine), 10% used a PI and 12-15% used a third nucleoside. The most non-recommended combinations were tenofovir-including (n=42) and triple-nucleoside plus NNRTI (n=36) regimens. Nine of the patients starting tenofovir had hepatitis B coinfection and seven of these patients also included 3TC in their initial combination.
Management of HIV and pregnancy
The audit was also used to assess current arrangements for testing pregnant women for HIV. Of 104 centres 10% offered an opt-in service, 88% an opt-out service and 3% a selective service. HIV clinician estimates for the percentages of women offered antenatal testing at 94 of these centres was:
|% women tested||number (%) of clinics|
Feedback from 2001 audit
Although results from the audit remain confidential, an important part of the project is to offer individual reports back to clinics so they can assess their own performance, and this opportunity was taken up by fewer than half of the clinics participating in the previous audit.
Six per cent of clinics reported that the audit process changed their clinical practice.
Summary findings from this preliminary report were therefore that:
- most centres report >15% rise in their HIV caseload over past year
- 38% of centres do not test VL until at least six weeks after starting ART
- significant delays can occur between diagnosis and starting ART even for patients with extremely low CD4 counts
- BP, glucose and/or lipids were not measured before starting ART in half of patients
- although many different drug combinations were used, most patients started on 2NRTI/NNRTI or other standard HAART.
Brook G, BHIVA audit and updates. Symposium session. 9th BHIVA Conference, 24-26 April 2003, Manchester.