Selected presentations at BHIVA: COVID-19, PrEP in the UK, community involvement and more…
The following review reports on some of the highlights from the 5th Joint BHIVA/BASHH conference, held this year as a virtual meeting.
Major themes included diverse aspects of COVID-19, PrEP and community-related research and also weight gain (reported in a separate article).
For full details of all the studies below, please see the online presentations.
COVID-19 in the UK
A wide range of studies on COVID-19 included the UK response to adapting UK services during lock down, the impact on HIV and sexual health, sexual behavior in response to guidelines and clinical outcomes of COVID-19.
Clinical outcomes of COVID-19
Two oral presentations – a BHIVA audit and early PHE data – both reported that HIV was independently associated with small but significant increased risks of worse outcomes from COVID-19. [1, 2]
Also that mortality was disproportionately higher in HIV positive people from black and Asian communities.
The causes are unclear but thought to be related to social factors that are difficult to fully adjust. Both studies were reported in the previous issue of HTB. [3, 4]
BHIVA COVID-19 vaccine guidelines
A review of upcoming changes in BHIVA guidelines included an update on vaccination guidelines focusing on those for COVID-19, currently out for comment. 
Produced against the challenge of a continued stream of new data, the panel reviewed limited data in HIV positive people. This included a single case of lack of vaccine response in someone with a very low CD4 count (20 cells/mm3) and high viral load. The guidelines strongly recommends vaccination for all people living with HIV, with whatever vaccine is offered – and noted the importance of further research to inform current research gaps.
Other talks in this session included updates from CROI 2021 by Laura Waters and on the BHIVA TB guidelines by Clare van Halsema.
Adapting UK health services during lock down
An early response to lock down included a move to virtual consultations, usually by phone, reduced monitoring, especially for people on stable ART and using ART that needed minimal support from laboratory services (including minimal need for resistance and HBV tests).
Some of these changes improved services some of which were previously planned but enabled more easily because of COVID-19.
Many studies reported on moving to virtual from face-to-face consultations and this was reported very positively including in a poster from NHS Grampian. In a survey of 44/48 HIV positive people rated telephone consultations at either 9 or 10 (out of 10). The preference for future consultations included 10/48 wanting face-to-face, 12/48 preferring telephone and 26/48 saying “it depends”. 
However, although all 19 staff saw the benefit of telephone consultations, only 35% preferred these.
A study from Newcastle presented an interim analysis of deferred viral load tests during 2020. Of 1110 people registered the previous year, 815 (73%) had a deferred viral load. 
Of these, just under half 68 of these had a viral result after the deferral, at a mean of 12 months (range: 8 to 20) since the previous test. Viral load responses were similar in for periods: 96% vs 94% <200 copies/mL and 82% vs 86% <50 copies/mL in previous vs deferral periods, respectively.
In those previously suppressed, 13 (4%) were detectable >200 copies/mL, with 7/13 having had historical periods of unsuppressed viral load in the previous five years.
Although the study in probably not powered for whether these differences were significant these data report include 10% of participants who appear to blip between 50 to 200 copies/mL.
In related study from Buckingham Health Trust reported no serious outcomes in 73 regular clinic attendees from deferred monitoring: one case of detectable viral load rapidly resuppressed and one case of increase in HbA1c was linked to weight gain. 
A study from Cardiff reported 45% reduction in visits by young people (aged 18 and younger) to sexual health services from 3278 in 2019 to 1789 in 2020. Although the largest group were aged 18, the services were access by people at all ages, including small numbers aged 13 and 12 and under. Reductions by age ranged from –28% to –50%. 
The impact of changes on HIV and sexual health: engaging in care and mental health
Several studies used the challenges of lock down to develop new services, with new approaches to testing, including for people who disengaged from care.
Changes is services for people who were previously homeless and included the chance for health interventions.
A London study reported on using COVID-19 as a time to contact people who were registered at the clinic but who had not attended since 2017, cross referenced to PHE records to check they had not transferred care. A new loss to follow up team (LTFU) identified 255 people plus another 181 who had not visited during the previous 12 months. 
This provided a group of 436 people disengaged from care, roughly half of which last had an undetectable viral load, but who were now likely to be off ART. This cohort had median age 46, was 59% male, 41% black African and 39% heterosexual. Only 18% answered the phone number on file.
By contacting people individually, 19 people returned to the clinic with 6/19 still undetectable though earlier visits. Of the 13 new re-engagements, 9/13 were women, with median 72 months (range: 58 to 99) since last visit. The median CD4 count was 279 cells/mm3(range: 94 to 574) and all patients are now back on ART.
Every successful link to care is clearly important but one of the questions pointed out the relatively high cost for few cases. The study show that LTFU remains an important problem and that many people are still do not engage with care.
A study from UCL used the temporary housing provided during lock down to provide testing and care for point of care testing for HIV, syphilis, HBV and HCV. 
Between May and October 2020, the service testing 1209 people at 66 venues. Approximately 80% were man and 50% were from black or minority ethnic groups. About half were previously sleeping rough. Mean length of homelessness was 2.3 years and about 40% had become homeless in the previous 6 months.
Overall, 35 were HIV positive (3%), with 6 newly diagnosed, 5 coinfected with HCV and 5 had interrupted ART due to problems accessing treatment during COVID-19. All 35 and now engaged with care and receiving peer support.
A study from Somerset NHS trust reported results from prospectively screen for anxiety and depression to look at the impact of COVID-19 on mental health of 160 HIV positive people (74% male). 
Based on the PHQ-9 and GAD-7 scores, 47 people (29%) developed a new mental health illness between March and November 2020.
Among the 120 (84 males, 35 females) with no previous mental health history, 19, 3 and 6 developed mild, moderate and severe depression respectively. The results for anxiety were 9, 5 and 5, respectively.
Overall, one third that a diagnosis of depression which was higher during COVID-19 but did not affect HIV treatment outcomes. However, social factors related to higher scores included COVID health concerns, inconsistency on advice for shielding, financial and family concerns and fake news on social media.
A community survey of sexual behavior completed by 918 gay men in London during COVID-19 included mainly cis men (5.4% were tans or non-binary), 82% were white and 20% were HIV positive.
Just under half (approximately 440) reported having casual partners from other households during lock down. This was significantly more likely in those younger than 40 years (vs older than 40), and in those who were HIV positive; both p<0.01.
However, nearly 60% of those having casual sex reported reduction risk of COVID-19 by washing/showering, less kissing, more condoms, wearing a mask etc. 
A retrospective case note review from a sexual health clinic in east London, reported an increase in cases of syphilis during 2020: 164 compared to 111 in the same period in 2019. Roughly one-third were primary, secondary and early-latent. Early cases were similar during and after lock down. Overall, 85% were self-referrals but 11% had tried to access help via a GP. 80% were male (of which 77% were gay men). The study noted that overall caseload increased after lockdown was relaxed and similar increases are expected now. 
Increased reports of domestic violence and other need for support
Researchers from Central North West London reported results from a renewed focus on domestic violence with guidelines for all doctors to routinely ask patients in consultations about whether this was an issue. The project included reminders doctors on a weekly basis and emphasised referral pathways. 
Although there were fewer appointments, routine screening improved from an average of 8% (range 0-19%) pre-lockdown to 33% (range 0-56%) post-lockdown.
Overall, 17 of domestic abuse were reported, with disclosure higher during lock down. Approximately 60% were male (70% gay men), with roughly 50% white and 50% Black. Importantly, for future services, most cases (89%) only disclose after being asked at more than one consultation, with one person only disclosing on the fourth time.
Several studies reported impact of COVID-19 on well-being and the need for support.
An anonymous cross-sectional survey in Brighton was completed by 653 HIV positive people with 385.653 also completed including qualitative free-text responses. Overall, 501 (77%) respondents were more anxious; 464 (72%) were more depressed; and 128 (29%) reported suicidal thoughts during the pandemic. 
HIV concerns included 40% worrying about supply of HIV meds, 38% on accessing HIV services and 63% on other health services. Half the respondents felt that more support could have been provided for HIV positive people.
On a more positive note, 80% thought their experience from HIV helped them deal with the difficulties of COVID-19.
Similar resilience was reported by 245 respondents to a anonymous community survey from Positively UK (response rate 43%). Demographics included 60% aged 45 to 64, 68% men, 69% white. 
Approximately 50% reported difficulties accessing HIV care during COVID-19 (often due to service closures) and 40% to general health care. Roughly 20% reported adherence difficulties, one third of which were linked to poor mental health.
PrEP access across the UK
PrEP was another key conference theme covering impact of COVID-19 (generally clinics reported maintaining services throughout lock down, though using reduced monitoring), current access across the UK, and reports on broadening access to other groups.
The importance of raising awareness of PrEP in under represented communities appropriately launched the main conference with short positive videos made with the Sophia Forum and Women and PreP. 
These clips include confident and positive community advocates talking about the importance of PrEP for women, sex workers, non-binary and transgender people and heterosexual Africans.
Three oral posters covered:
- Baseline demographics for the 25,000 largely white gay men enrolled in PrEP Impact Trial (now ended). 
- A community project looking to raise awareness of PrEP in black African heterosexual populations in the UK. 
- A focus on improving adherence and supporting people to continue PrEP based on a two-year programme in Scotland. 
A retrospective review from Swansea reported continuing the PrEP service from March 2020 that included starting PrEP in 66 new cases (compared to 102 during the same period in 2019). The clinic moved to telephone consultations and manged similar monitoring for STIs and renal function. This poster also reported 11 new HIV diagnoses, which was similar to the previous year. 
A lunchtime workshop on Wednesday included a panel of speakers to summarise current access to PrEP across the UK. This is an excellent review of latest access details. Although the webcast is apparently online, the URL was difficult to find. 
Community engagement with the BHIVA conference
The BHIVA conference always includes strong community involvement in the programme.
Case study: Angelina Namiba
This year included a case study presented by an HIV positive patient who is also one of the UK’s leading treatment advocates. For most of the last two years, with a diagnosis still not fully resolved, Angelina Namiba from the 4M Network of Mentor Mothers presented her own case story. 
This included a traumatic and serious mass that was not identified by biopsy or other tests. This included a long period of hospitalisation including several hospital transfers.
It was notable how some aspects of care were difficult to navigate, even for an experienced advocate. The presentation notably moved other doctors involved in the presentation and is highly recommended for community and health workers. 
UK-CAB workshop: what keeps me awake at night
The UK-Community Advisory Board (UK-CAB), a network of more than 800 community advocate also organised one of the workshop in the main programme on Monday. 
This session included personal perspectives from three leading UK activists: Ant Babajee, Leasuwanna Griffiths and Husseina Hamzaa. These talks covered experiences of the COVID-19 vaccine, HIV and pregnancy, quality of sleep, peer support and issues of mental health and how these issues affect different populations.
There were also many community-led research studies presented as oral and poster presentations, some of which are already reported above.
It is always good to see BHIVA continue working closely with people living with HIV.
Unless stated otherwise, all references are to the programme and abstracts to the 5th Joint BHIVA BASHH Spring Virtual Conference, 19–21 April, 2021.
- Sabin C et al. Coronavirus (COVID)-19 in people with HIV in the UK: Initial findings from the BHIVA COVID-19 Registry. Oral abstract O008.
- Croxford S et al. COVID-19 mortality among people with HIV compared to the general population during the first wave of the epidemic in England. Oral abstract O009.
- Collins S. BHIVA registry reports HIV is independently linked to worse presentation and outcomes from COVID-19. HTB (3 May 2021).
- Collins S. HIV is linked to higher mortality from COVID-19 compared to HIV negative: 60% of deaths were black ethnicity. HTB (3 May 2021).
- Geretti A-M et al. BHIVA vaccine guidelines update.
- Yasotharan K et al. P193 Sexual & Reproductive Health telemedicine appointments during COVID-19. Poster abstract P193.
- Welsh S et al. Deferral of routine HIV viral load monitoring during the COVID-19 pandemic. Oral abstract 026.
- Bailey A et al. Evaluation of outcomes from deferred HIV monitoring in the context of the Covid19 pandemic. Poster P171.
- Davies B et al. Impact of COVID 19 on access to sexual health clinics for patients 18 years old and under. Poster abstract P86.
- Ottaway Z et al. Going backwards on the treatment cascade? Identifying and reengaging people living with HIV (PLWH) who are lost to follow up (LTFU). Oral abstract 025.
- Sultan B et al. High prevalence of HIV among people who experience homelessness in London: results of an innovative peer-centred outreach bloodborne virus testing service initiated, at the start of the COVID-19 pandemic. Oral abstract O010.
- William ST et al. The impact of COVID pandemic on mental health in people living with HIV – a UK HIV clinic cohort study. Poster abstract P028.
- Wang D et al. A study of MSM sexual behaviours in London during COVID-19 restrictions. Poster abstract P031.
- Chung E et al. P060 Syphilis in East London during the COVID19 lockdown. Poster abstract P60.
- Ahmed N et al. Domestic abuse screening in people living with HIV. Poster abstract 188.
- Pantelic M et al. “I have the strength to get through this using my past experiences with HIV”: A mixed-method survey on health and wellbeing among people living with HIV during the Covid-19 pandemic. Poster abstract 122.
- Petretti S et al. P130 “For me, it is my second pandemic”: Experiences of people living with HIV accessing support from Positively UK during COVID-19. Poster abstract P130.
- Impact Trial PrEP videos. Raising awareness in underserved populations.
- Sullivan A et al. The HIV pre-exposure prophylaxis (PrEP) Impact trial: baseline demographics, coverage and first regimen choice
. Oral abstract O013.
- MacDonald J et al. How to improve PrEP adherence and retention in care: insights and recommendations for the first two years in in Scotland.
Oral abstract O014.
- Kifetew CA et al. HIV Pre-exposure Prophylaxis and Black people in England: Addressing health information inequalities through a national campaign. Oral abstract O015.
- Bradshaw H. Pre-exposure prophylaxis (PrEP). Poster abstract P078.
- Lunchtime Workshop – PrEP across the UK. Wednesday 21 April 2021.
- Namiba A. They held my hand. Clinico-pathological Case & patient perspective.
- Checkley A and Gil E. In Search of a diagnosis.
- Ant Babajee,
Leasuwanna Griffiths, Husseina Hamzaa. UK-CAB Workshop
”What keeps us awake at night”. Lunchtime workshop.