GP facilitators and HIV infection: Heterosexual infection less common than other routesBMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6927.538a (Published 19 February 1994) Cite this as: BMJ 1994;308:538
- B Davis
EDITOR, - Peter Saunders rightly draws attention to the fact that an increasing proportion of newly diagnosed HIV infections in Britain is attributable to heterosexual intercourse; his statement that this is now the commonest mode of spread in Scotland merits comment.1 Since 1985 the Communicable Diseases (Scotland) Unit has maintained a register, based on laboratory reporting, of all people known to be infected with HIV in Scotland. As it is based on voluntary testing this register cannot be seen as an indication of incidence or prevalence, but it remains the most reliable source of data on HIV infection in Scotland and is used in resource allocation under the AIDS (Control) Act and in official predictions of the course of the HIV epidemic.
The table shows the distribution of newly diagnosed HIV infections by probable category of transmission and by year of specimen (since 1985) according to the Scottish HIV register.
Overall, the decreasing predominance of injecting drug use as a category of transmission and the increasing predominance of heterosexual transmission are clearly apparent, but in only one year (1992) has heterosexual intercourse been the commonest mode of spread. In 1993 sexual intercourse between men accounted for the highest proportion of cases, followed by injecting drug use.
Shared care better for GPs and specialists
- L Grun,
- E Murray
EDITOR, - We agree with Peter Saunders about the importance of general practitioners providing more of the care for HIV positive patients,1 but facilitators are not the only means of achieving this. The departments of primary health care and genitourinary medicine at University College London Medical School have collaborated in setting up a formal shared care protocol for asymptomatic HIV positive male patients. The aim of the study is to ascertain whether shared care is appropriate for these patients.
Patients attending the genitourinary clinic at the Middlesex Hospital are invited to participate in the study. Once a patient has agreed, his general practitioner is contacted and asked if he or she is willing to provide the necessary care; if the answer is yes the patient is enrolled in the study. The patient holds a “co-op card, “ which contains a summary of the relevant medical history, a record of any drug prescribed, and a chart for completion at each consultation. All baseline investigations are done at the clinic; subsequently the patient attends his general practitioner at three monthly intervals for a check up and is reviewed at the hospital annually.
We believe that the advantages of this approach include the opportunity to form a therapeutic doctor-patient relationship early on, when the patient is still well; the possibility of continuity of care for the patient from his own general practitioner, which relieves the pressure on appointments at the hospital and allows specialist physicians to concentrate on patients most in need of their skill; and the fact that the general practitioner can gain both confidence and competence in caring for patients with HIV infection through a structured protocol of care.
An initial questionnaire indicated that about half the patients would be interested in increasing the involvement of their general practitioner in their care.2 Recruitment of patients has, however, been slower than was suggested by the results of the questionnaire - reflecting perhaps both the reluctance referred to by Saunders and the strength of the doctor-patient relationship already established in the genitourinary clinic at the Middlesex Hospital.
GPs should be involved early
- B Guthrie,
- F Stinton,
- G Reilly,
- S Barton
EDITOR, - Peter Saunders highlights the importance of general practitioner facilitators in the context of HIV infection and indicates that the role of these facilitators will vary depending on the prevalence of HIV infection in the area they serve.1 In areas of low prevalence the emphasis will be on prevention; in areas of higher prevalence clinical management and organisation of care at home become increasingly prominent.
The statement that “on average every general practitioner may ... expect to have one HIV positive patient on his or her list” must, however, be qualified. In reality, most patients are concentrated in large cities. Even within these cities the prevalence of HIV infection varies considerably. This unit is in contact with several hundred general practitioners, but the 31% of our patients who are known to be registered with a general practitioner are registered with just 20 practices. In our experience, many patients move to be closer to our unit as they become more sick. This further concentrates the workload related to HIV infection into a small number of practices.
In London the care of people with HIV infection was initially provided in genitourinary clinics and community services were marginalised.*RF 2,3 Increasingly, more care is being provided in the community, partly by specialist teams organised by hospital units and partly by general practitioners and district nurses. One of the problems with hospital based teams is that they may continue to marginalise generic services, including those provided by general practitioners,3 despite a stated aim of increasing general practitioners' participation in these patients' care.4,5 Although contact with a home support team increases registration with and disclosure to general practitioners, it also reduces use of general practitioners by about a quarter of the people using the service.4
The community liaison team at Chelsea and Westminster Hospital does not itself provide any home care as we firmly believe that the best people to provide medical and nursing care in the community are general practitioners and generic district nurses. Instead we seek to involve those working in primary care in the early stages of illness and to coordinate the many agencies that may help patients with late stage HIV infection. It is essential that we work in partnership with general practitioners and their facilitators to encourage more general practitioners to achieve the high standards of care of patients with HIV infection provided by many of their colleagues.
Other health professionals can be facilitators
- H Lempp,
- E Rink
EDITOR, - Peter Saunders suggests that general practitioners are ideally placed to work as facilitators in HIV infection and AIDS, 1 but so are other people. Colleagues who are primary health care facilitators in HIV infection and AIDS and sexual health come from a wide variety of professional backgrounds and are also highly qualified to understand the difficulties that primary health care teams encounter in dealing with people with HIV infection or AIDS living in the community.
Although, as Saunders says, facilitation includes an educational role, it can go much further. After diagnosis people with HIV infection or AIDS spend 80% of their remaining lives in the community;2 thus enhancing direct treatment by primary care staff is a second key role for facilitators. Thirdly, the preventive aspect of facilitation is crucial: the Health of the Nation identified primary health care teams as important in promoting sexual health.3
We have recently reviewed the outcomes of six projects to distribute condoms in England, and the implications are clear - namely, that it is appropriate for general practices to distribute condoms and they are effective at doing this.4 Essentially, success will depend on training staff in issues regarding sexual health; conveying straightforward information on types of condom, their use for contraception, and their application; and having clear and agreed protocols on use of condoms.5
The primary health care team, with the help of the facilitator, is in a unique position to be directly involved in preventing HIV infection as well as in managing its consequences and providing terminal care and bereavement counselling. But current practice is often poor. Proper procedures for needlestick injuries, standardised safe venepuncture, the use of central venous lines, shared care cards, and HIV employment policies for general practice are often neglected. Facilitators, whether doctors, nurses, or other health professionals, can bridge these gaps between primary and secondary care.
Evaluation is needed
- S Singh,
- M King,
- K Bashir
EDITOR, - Though we agree that general practitioners ought to be given more help in caring for people with HIV infection, how this help should be offered and used is unclear. In his editorial Peter Saunders promotes the idea of a facilitator without considering whether it should be evaluated.1 acilitators in HIV infection and AIDS have worked in a variety of funded posts for the past seven years, 2,3 and such a widely adopted initiative should now be systematically assessed. This assessment should include getting the views of patients with HIV infection and AIDS4 and members of the primary health care team as to whether facilitation is of practical benefit. Such an evaluation should determine whether facilitation is effective and, if so, whether it requires modification to meet the needs of those it sets out to serve.