HIV services – what role for primary care?

To date, antiretroviral therapy for HIV-infected patients in the UK has been managed almost exclusively by specialists in secondary care. However, changes in the disease's nature challenge this approach. High rates of new diagnoses (6,750 in 2010),1 earlier initiation of therapy and increased life expectancy have led to a growing and ageing cohort of patients. Estimates suggest that by 2012 over 100,000 people in the UK will have HIV infection, with one in five being aged over 50 years.2,3 HIV infection has therefore become a chronic disease requiring lifelong treatment. Such changes should prompt a re-evaulation of the most appropriate setting for patients' care, and the potential for transferring HIV care to the primary sector setting merits consideration.

Several factors argue for this change. Antiretroviral regimens have become simplified, and cause fewer adverse effects than previously. So, many patients remain stable on their regimen for long periods and require only periodic monitoring, which could be done in primary care. Also, the promotion of routine testing for HIV outside traditional settings will lead to an increasing proportion of diagnoses occurring in primary care, and HIV-infected patients are increasingly willing to share information with their GP. Furthermore, co-morbidities that occur commonly in an ageing population are more frequent in patients with HIV infection, leading to more people needing to attend primary care because of conditions such as hyperlipidaemia, hypertension and diabetes. Greater involvement of primary care physicians in antiretroviral prescribing might also help to prevent prescribing errors related to a patient being treated by multiple prescribers in multiple locations, a particular concern given that around one in six medications prescribed in primary care for HIV-infected patients has the potential for major interactions with antiretrovirals.4

This is not to say that all bar the most difficult HIV management …