Results
Case-note review data was provided for 8258 patients from 123 sites, but only 112 services completed the survey of clinic practices. The 8258 individuals included in the case-note review represent approximately 10% of PLWH reported in public health surveillance as attending UK HIV services [
2]. Two thirds were male, just over half (52.3%) acquired their HIV heterosexually, the majority were of white ethnicity (58.8%) and 60.6% were in the 30–49 year age group (see Table
1). 62.0% (5119/8258) of patients had been reviewed within three months up to audit data extraction in June–August 2015 and 96.5% (7971/8258) had been reviewed within 1 year. While it is difficult to perform a direct comparison, the characteristics of our study population are similar to the reported demographic data on people living with HIV in the UK [
1].
Table
2 shows the proportion of individuals achieving the audit standards for all audited recommendations.
Table 2
Clinical monitoring standard examined and performance
Whether a baseline HIV resistance test had been done or sample stored for later testing | Patients with a genotypic resistance test performed within 3 months of first diagnosis (or with a stored sample available for later testing) (90%). | 80.8% (6636/8258 tested, 40/8258 sample stored) |
Whether HIV viral load measured within past 6 months | Patients on ART with HIV viral load measured within the last 6 months (80%). | 90.1% (6660/7395) |
Whether adherence assessed within past 425 days | Adherence documented within the first 3 months of starting ART (90%) and at least annually thereafter (70%). | 93.4% (6908/7395) |
Whether all medication recorded within past 425 days | All medication taken by patients on ART should be reviewed annually (100%). | 89.0% (6584/7395) |
Whether vaccinated/immune to hepatitis A | No target specified but serology recommended followed by vaccination for all non-immune at risk and/or co-infected with hepatitis B or C. | 61.2% (5053/8258) |
Whether hepatitis B serology recorded; whether anti-surface antibody measured within past 425 days for individuals with serology consistent with vaccination | No target specified but surface antigen (HBsAg), anti-core total antibody (anti-HBc) and anti-surface antibody (anti-HBs) testing recommended. Vaccination recommended if non-immune. Annual surface antibody titre measurement recommended in vaccine responders. | 82.1% (6781/8258) |
Whether hepatitis C antibody status known | No target specified but antibody testing recommended, followed by RNA testing if antibody positive. Annual re-testing recommended for antibody negative men who have sex with men (MSM) or injecting drug users (IDU). | 96.6% (7979/8258) |
Whether CVD risk assessed, within past 3 years if on ART, ever if not on ART | 10-year cardiovascular disease (CVD) risk calculated within 1 year of first presentation (70%), and within the last 3 years if taking ART (70%). | 44.9% (3318/7395) on ART 32.3% (279/863) |
Whether smoking status recorded within past two years; if a smoker, whether offered a cessation service. | Smoking history documented in the last 2 years (90%) and if a smoker offered referral to a cessation service (90%). | 65.9% (5445/8258) 45.2% (862/1905) offered cessation |
Whether blood pressure recorded within past 425 days | Blood pressure (BP) recorded in the last year (90%). | 85.5% (7058/8258) |
Whether glucose measurement recorded within past 425 days | No target specified but recommended yearly or 3–6-monthly if on ART. | 77% (6359/8258) |
Whether lipid profile recorded within past 425 days | No target specified but recommended yearly or 6–12-monthly if on ART. | 83.2% (6869/8258) |
Whether liver function test (LFT) assessed within past 425 days | No target specified but recommended yearly or 3–6 monthly if on ART. | 97% (8013/8258) |
Whether estimated glomerular filtration rate (eGFR) assessed within past 425 days | No target specified but recommended yearly or 3–6 monthly if on ART. | 95.5% (7887/8258) |
Whether urinalysis or urine protein/creatinine (uP/C) checked within past 425 days, or 243 if receiving tenofovir | No target specified but urinalysis and uP/C recommended annually, with 3–6-monthly urinalysis if receiving tenofovir. | 73.7% (2050/2781) 74.8% (4098/5477) receiving tenofovir |
Whether flu vaccination had been done or record made of advice to obtain this from general practitioner (GP) within past year: as audit was conducted in summer this fully covered the preceding season | No target specified in monitoring guidelines but vaccination history recommended as part of regular clinical review. Vaccination guidelines specify: offer annual influenza vaccination to all HIV-infected persons (target 95%) [ 14]. | 21.1% (1744/8258) vaccination given 36.2% (2993/8258) advice given |
Whether sexual health screen offered within past 425 days | No target specified but recommended to offer sexual health screen 12-monthly, or more frequently if identified risks. | 65.7% (5424/8258) |
Whether syphilis serology had been done within past 243 days | No target specified but recommended 3–6-monthly at each routine visit for MSM and 12-monthly for others | 63.0% (5201/8258) |
Whether cervical cytology had been done or record made of advice to obtain elsewhere within past 425 days, females only | No target specified but recommended 12-monthly. | 53.2% (1471/2763) |
Whether bone mineral density measured, individuals aged >70 and on ART only | No target specified but recommended in all men aged 70 years and all women aged 65 years. | 17.4% (29/167) |
Whether fracture risk assessed within past 3 years, individuals aged >50 only | No target specified but recommended 3-yearly if aged over 50 years. | 16.7% (430/2568) |
Outcome: whether vaccinated against pneumococcus, CD4 > 200 only | No target specified in monitoring guidelines but vaccination history recommended as part of regular clinical review. Vaccination guidelines recommend pneumococcus vaccination if CD4 > 200, and consideration of vaccination at lower CD4. | 26.4% (2082/7877) |
Baseline resistance testing
While the majority of audited cases met the national standard for baseline resistance testing (see Table
1), almost 1 in 5 (19.2%,
n = 1586/8258) individuals did not. However baseline resistance testing was recorded as “not possible” for 47.3% (750/1586); 7.1% (112/1586) had neither been tested nor had a sample stored; and for 45.4% (720/1586) it was not known whether this had been done or the question was not answered.
Antiretroviral treatment
Of 89.5% (7395/8258) audited individuals who were on ART, 90.1% (6660/7395) had a HIV viral load measurement within the past 6 months, exceeding the guideline target of 80%, and 93.4% (6908/7395) had had ART adherence assessed in the last year, which outperformed the target of 70%. However, only 89.0% (6584/7395) had all other medications recorded within the last year, despite a target of 100% to avoid drug-drug interactions.
Viral hepatitis
Among audited individuals, 61.2% (5053/8258) were hepatitis A vaccinated, immune, or seropositive, 11.9% (n = 983/8258) were seronegative, 0.02% (2/8258) equivocal, and for 26.9% (2220/8258) it was not known whether this had been done or the question was not answered.
In terms of hepatitis B, 82.1% (6781/8258) individuals had serology fully reported (hepatitis B surface antigen HBsAg, hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs)); 0.9% (72/8258) were HBsAg positive with incomplete antibody status; 10.2% (841/8258) were HBsAg negative with incomplete antibody status; 6.8% (564/8258) had unknown HBsAg status or the question was not answered. Among 306 chronic hepatitis B infected (HBsAg+) individuals, 7.8% (24/306) were apparently unvaccinated and seronegative for hepatitis A. Among 3605 individuals whose status was consistent with vaccination (anti-HBs+, anti-HBc- and HBsAg-), 67.0% (2416) had had an annual anti-HBs measurement.
Hepatitis C antibody (anti-HCV) status was negative for 91.3% (7539/8258) individuals, positive for 5.3% (439/8258), equivocal for 0% (1), not known or the question was not answered for 3.4% (279/8258). Among the 7539 seronegative individuals, 65.4% (4928) had had an annual re-test including 74.1% (2423/3270) men who have sex with men (MSM) and 61.8% (21/34) injecting drug users (IDU), groups in whom this is recommended. Hepatitis C RNA (ribonucleic acid) testing had been done for 91.1% (400/439) anti-HCV positive patients. Data on HCV genotyping were not collected.
Cardiovascular health
Only 44.9% (3318/7395) of patients on ART had a documented 10-year CVD risk within the past three years. Of those not on ART, 32.3% (279/863) had 10-year CVD risk recorded at any time, despite targets of 70% for both groups. ART status was unclear for 18 patients. Among 1582 patients aged >50 years on ART, with no documentation of established CVD, almost half (48.7%; 770) had CVD risk calculation recorded within the last 3 years.
Smoking status had been documented within the past two years for 65.9% (5445/8258) audited patients, well below the target of 90%. Only 45.2% (862/1905) of current smokers had been offered a cessation service although this is recommended [
9]. Current smokers were not more likely to have CVD risk calculated than ex or never smokers.
Sexual and reproductive health
An annual sexual health screen was recorded as offered for 65.7% (5424/8258) of all patients, including 72.7% (2581/3550) MSM, and 60.8% (2627/4320) heterosexuals. Syphilis serology was recorded within the past eight months (243 days) for 63.0% (5201/8258) of all patients, 73.4% (2604/3550) MSM, and 55.3% (2390/4320) heterosexuals.
Out of 2763 women, 53.2% (1471) had annual cervical cytology done and 21.9% (604) had been advised to attend a GP or sexual health clinic for this. The self-audit spreadsheet tool did not provide an option for women ineligible for cervical cytology. Contraception was reported not relevant for 31.7% (877/2763) of women. It had been discussed for 63.0% (1188/1886) women for whom it was relevant.
Bone health
Fracture risk had been assessed within the past three years for only 16.7% (430/2568) patients aged over 50 years. Bone mineral density had been measured in 17.4% (29/167) individuals aged over 70 years and receiving ART. For simplicity, the spreadsheet recorded this from age 70 for both sexes although guidelines recommend it from age 65 in females.
Variation in monitoring between participating sites
There was wide variation in resistance testing across sites. 27% (33/123) sites met the target, having a recorded resistance test or stored sample for >90% of audited individuals while 27% (33/123) sites achieved this outcome for <75% of audited individuals, including 4.9% (6/123) sites who did so for <60%.
There was variation between sites in the proportion of patients for whom HBsAg status was not known, and for 8 sites this exceeded 20%. There was wide variation across sites in provision of influenza vaccination with 16/123 sites having administered or advised obtaining influenza vaccination at their general practitioner (GP) or Pharmacy for fewer than 10% of patients and 17/123 sites for more than 90% of patients.
There was wide variation in CVD risk calculation between sites; of 122 sites submitting data for patients receiving ART, 21.3% (26) met the 70% target for CVD risk recording within three years but 27.9% (34) achieved this for fewer than 20% of patients. There was also variation across sites for fracture risk assessment.
Monitoring frequency
Most survey respondents routinely reviewed patients who were stable on antiretroviral therapy every 6 months, when HIV viral load (VL) was also checked. CD4 counts were less frequently measured (see Table
3). Sexual health screening was provided within 96.4% (108/123) of HIV services, cervical cytology within 71.4%(80/123) of HIV services and influenza vaccination within 71.4%(80/123) of services.
Table 3
Frequency of routine monitoring for individuals virologically stablea on ART (112 clinical services)
3 monthly | 4 (3.6%) | 6 (5.4%) | 5 (4.5%) |
4 monthly | 17 (15.5%) | 24 (21.4%) | 16 (14.3%) |
6 monthly | 74 (66.1%) | 78 (69.6%) | 42 (37.5%) |
Yearly | 10 (8.9%) | 1 (0.9%) | 45 (40.2%) |
Other or not answered | 7 (6.3%) | 3 (2.7%) | 4 (3.6%) |
Acknowledgements
Members of the BHIVA Audit and Standards Sub-Committee: A Freedman (chair), B Angus, D Asboe, F Burns, R Byrne, D Chadwick, D Churchill, H Curtis (co-ordinator), V Delpech, K Doerholt, A Molloy, J Musonda, N Naous, O Olarinde, E Ong, S Raffe, C Sabin, A Sullivan. The committee and authors would like to thank all HIV clinical services who submitted audit data, and S Michael, M May and M Gompels of Bristol University for conducting further analyses.
Participating clinical services: Area Infection Unit, Monklands Hospital, Airdrie; Tameside and Glossop Centre for Sexual Health, Ashton Primary Care Centre, Ashton-under-Lyne; Department of GU Medicine, Ysbyty Gwynedd Hospital, Bangor; Department of Integrated Sexual Health and HIV Medicine, Barking Community Hospital, Barking; Clare Simpson Clinic, Barnet General Hospital, Barnet; Department of GU Medicine, Barnsley Hospital NHS Foundation Trust, Barnsley; Department of Sexual Health, Solent NHS Trust, Basingstoke; Department of GU Medicine, Royal United Hospital, Bath; Beckenham Beacon Sexual Health Clinic, Beckenham Hospital, Beckenham; Department of GU Medicine, Bedford Hospital, Bedford; Department of GU Medicine, Royal Hospitals Trust, Belfast; Department of GU Medicine, Birmingham Heartlands Hospital, Birmingham; Department of HIV Medicine, Queen Elizabeth Hospital, Birmingham; Department of GU Medicine, Blackburn Royal Infirmary, Blackburn; The Pannel Suite Clinic, Royal Bournemouth Hospital, Bournemouth; Lawson Unit (HIV) Outpatients, Royal Sussex County Hospital, Brighton; Department of Immunology, Southmead Hospital, Bristol; Department of GU Medicine, West Suffolk Hospital, Bury St Edmunds; Department of GU Medicine, Frimley Park Hospital, Camberley; Infectious Diseases & HIV/GU Medicine Clinic 1A, Addenbrooke’s Hospital NHS Trust, Cambridge; The Gate Clinic, Kent & Canterbury Hospital, Canterbury; Department of GU Medicine, Cardiff Royal Infirmary, Cardiff; Infectious Diseases Unit, University Hospital of Wales, Cardiff; Department of GU Medicine, St Helier Hospital, Carshalton; Department of GU Medicine, Mid Essex Hospital Services NHS Trust, Chelmsford; The Blanche Heriot Unit, St Peter’s Hospital, Chertsey; Department of GU Medicine, Countess of Chester Hospital NHS Trust, Chester; Department of GU Medicine, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield; Fletcher Unit of Sexual Health, St Richard’s Hospital, Chichester; Department of GU Medicine, Essex County Hospital, Colchester; Department of Sexual Health, Leighton Hospital, Crewe; Department of GU Medicine, Croydon University Hospital, Croydon; Department of GU Medicine, Derbyshire Royal Infirmary NHS Trust, Derby; Department of GU Medicine, Dewsbury and District Hospital, Dewsbury; Department of GU Medicine, Downe Hospital, Downpatrick; Department of GU Medicine, Russells Hall Hospital, Dudley; Department of GU Medicine, University Hospital of North Durham, Durham; Department of Sexual Health, Avenue House Sexual Health Clinic, Eastbourne; Department of GU Medicine, Lothian University Hospitals, Edinburgh; Regional Infectious Diseases Unit, Western General Hospital, Edinburgh; Exeter NHS Walk-in Centre, Exeter; Borders Sexual Health, Galashiels; Trinity Square Health Centre, Gateshead; Department of GU Medicine, Gartnaval General Hospital, Glasgow; Department of GU Medicine, Gloucestershire Royal Hospital, Gloucester; Department of GU Medicine, Orsett Hospital, Grays; Department of GU Medicine, Bure Clinic, James Paget Hospital NHS Trust, Great Yarmouth; Department of Sexual Health, Buryfields Clinic, Guildford; Department of GU Medicine, Northwick Park Hospital, Harrow; Sexual Health Clinic, Station Plaza Health Centre, Hastings; Gaol Street Health Centre, Wye Valley NHS Trust, Hereford; Department of GU Medicine, Wycombe General Hospital, High Wycombe; Department of GU Medicine, Huddersfield Royal Infirmary, Huddersfield; Sexual Health Clinic, Wilberforce Health Centre, Hull; The Oak Tree Centre, Huntingdon; Orwell Clinic, Ipswich; Department of Sexual Health, West Middlesex University Hospital, Isleworth; Department of Infectious Diseases, Worcestershire Acute Hospitals NHS Trust, Kidderminster; Department of GU Medicine, Queen Elizabeth Hospital, King’s Lynn; The Wolverton Centre, Kingston Hospital, Kingston upon Thames; Department of Sexual Health, Whytemans Brae Hospital, Kirkcaldy; Leatherhead GUM Clinic, Leatherhead Hospital, Leatherhead; Department of GU Medicine, Leeds General Infirmary, Leeds; Infection and Travel Medicine Unit and GU Medicine, Leeds Teaching Hospitals NHS Trust, Leeds; Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool; Department of GU Medicine, Royal Glamorgan Hospital, Llantrisant; 56 Dean Street, Chelsea and Westminster Hospital, London; Caldecot Centre, King’s College Hospital, London; Centre for Sexual Health and HIV Research, Mortimer Market Centre, London; Department of GU Medicine, University Hospital Lewisham, London; Department of GU Medicine/HIV, Newham University Hospital, London; Department of HIV Medicine, Royal Free London NHS Foundation Trust, London; Department of Sexual Health, Homerton University Hospital NHS Foundation Trust, London; Harrison Wing, St Thomas’ Hospital, London; HIV/GUM Directorate: St Stephen’s Centre, Chelsea and Westminster Hospital, London; Jefferiss Wing Centre for Sexual Health, Imperial College Healthcare NHS Trust, London; Patrick Clements Clinic, Central Middlesex Hospital, London; The Ambrose King Centre, The Royal London Hospital, London; Trafalgar Clinic, Queen Elizabeth Hospital, London; West London Centre for Sexual Health, Charing Cross Hospital, London; Department of GU Medicine, Luton & Dunstable Hospital NHS Trust, Luton; Rubin Clinic, Department of GU Medicine, Maidstone Hospital, Maidstone; Department of GU Medicine, Manchester Royal Infirmary, Manchester; Department of Infectious Diseases, James Cook University Hospital, Middlesbrough; Department of GU Medicine, New Croft Sexual Health Centre, Newcastle upon Tyne; Department of Infection & Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne; Department of GU Medicine, Cordell Centre, Royal Gwent Hospital, Newport; Sexual Health Service, St Mary’s Hospital, Newport; Department of Sexual Health, Northampton General Hospital, Northampton; Department of GU Medicine, Grove Clinic, Norfolk & Norwich University Hospital, Norwich; Department of GU Medicine and HIV, Nottingham City Hospital, Nottingham; Department of GU Medicine, George Eliot Hospital NHS Trust, Nuneaton; Oldham Sexual Health Service, Royal Oldham Hospital, Oldham; Department of GU Medicine, Oxford Radcliffe NHS Trust, Oxford; Department of Infectious Diseases, Oxford Radcliffe NHS Trust, Oxford; iCaSH Peterborough, Peterborough and Stamford NHS Foundation Trust, Peterborough; Department of GU Medicine, St Mary’s Hospital, Portsmouth; Florey Unit, Royal Berkshire Hospital, Reading; Department of GU Medicine, Doncaster & Bassetlaw Hospitals NHS Foundation Trust, Retford; Department of Sexual Health, Glan Clwyd District General Hospital NHS Trust, Rhyl; Department of GU Medicine, Rotherham NHS Foundation Trust, Rotherham; Department of GU Medicine, Hospital of St Cross, Rugby; Sexual Health Department, Salisbury District Hospital, Salisbury; Department of GU Medicine, Royal Hallamshire Hospital, Sheffield; One to One Centre, Shiremoor; HIV/GUM Directorate, Upton Hospital, Slough; Department of GU Medicine, Ealing Hospital, Southall; Department of GU Medicine, Royal South Hants Hospital, Southampton; Department of GU Medicine, Southport & Ormskirk NHS Trust, Southport; Department of GU Medicine, St Helen’s and Knowsley Hospital, St Helens; Department of Microbiology and GU Medicine, Jersey General Hospital, St Helier; Department of GU Medicine, Sunderland Royal Hospital, Sunderland; Department of GU Medicine, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield; Department of GU Medicine, Singleton Hospital, Swansea; Department of GU Medicine, Musgrove Park Hospital, Taunton; Department of GU Medicine, Royal Cornwall Hospital, Truro; Department of GU Medicine, The Hillingdon Hospital, Uxbridge; Josephine Butler Centre, King Street Health Centre, Wakefield; Department of GU Medicine, South Warwickshire General Hospitals NHS Trust, Warwick; Department of GU Medicine, Weymouth Community Hospital, Weymouth; Department of GU Medicine, Arrowe Park Hospital, Wirral; Sexual Health Services, Worthing; Department of GU Medicine, York Hospitals NHS Trust, York.