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Um, and I used and I used to work in an HIV clinic. So I'm going to be discussing HIV really from the sort of primary care point of view rather than from the HIV specialist point of view. Um, some of this has sort of elements of public health in it, and and obviously I've used English guidelines, but I'll try and make this as internationally relevant as I can. Those are my declarations of interest and a few thank you. And I should point out that although this talk is on our cgp slides, it's not given on behalf of the our Cgp. So what is HIV? It's a retro virus, which is transmitted via bodily fluids. So sexual transmission vertical transmission from mother to child, although we'll see later that that is very much not really an issue these days with good treatment, um, and and can be transmitted through through dirty needles. Um, it infec destroys the CD four cells, which are a subset of T lymphocytes and if not picked up, the person becomes profoundly immunocompromised and can die from infections or cancers. Um, more than two thirds of those who have HIV worldwide live in Africa. But the there is a has been lately, a massive drop over the last 20 years or so, a massive drop in, um in infections and in deaths. And I'll come on and talk a bit more about why that is. There is currently no vaccine available and no realistic cure. One person in the world has been cured of their HIV after they had whole body irradiation and then a bone marrow transplant for a blood cancer. But that's a little bit drastic to use to cure most people of their HIV. Um, so, uh, CD four count is not something we we usually really test if we're not thinking about HIV. So I thought it was useful to sort of give a rough picture of what an average CD four count means. So you start at the left of this. You can see that an average person has somewhere between 615 100 CD four cells. The unit is cells per millimeter cubed. Um, so if you say maybe sort of 77, 808 900 as an average, um, when you get HIV, that's the point. With the picture of the virus and the lightning flash. You have a big drop in your CD four count, and then it comes back up again. Um, and then it gradually goes down. When I worked in an HIV clinic, the guidelines were that we monitored people CD four count, and we didn't treat until it got to a certain level, which is not the guidelines now. And so I clearly saw all these different groups that we had a few slow progressors who we've been monitoring for years, and they're CD four count was more or less the same. We had fast progressors who's CD four count just plummeted within a year of diagnosis, and we had your sort of average progressor who drops maybe, um uh, 80 or so per year. Um, but this, um, diagram predates new guidelines, so you can see it, says a R V, which is antiretroviral drugs after two or three years after 7 to 8 years. The guidance now is that everyone should be treated at diagnosis with antiretroviral drugs because there's a clear survival benefit in doing that. So what is AIDS AIDS acquired? Immune deficiency syndrome is the progression of HIV, so it's the point at which your CD four count has dropped to the point that you are getting your immune system is clearly compromised and you're getting infections or cancers from that in the United States. They also define AIDS as having a CD four count of less than 200. But in the UK, we don't we only divide define it by these AIDS defining conditions. So if someone has HIV and they have one of these conditions than they have AIDS, all of these conditions are much less common now than they were in the past because antiretroviral treatment has been such a huge success. So let's just let's just go back and this does make me think of it. You know, in 1981 suddenly there was this weird new pneumonia and no one knew how to treat it, and there was no test for it, and lots of people died. Well, that sounds quite familiar to 2020 doesn't it? Um, but within a couple of years, well, within much less than a couple of years, we had a test and within a couple of and and then we had treatments, and within a couple of years, we have specific treatments and a vaccine it took three years after the first cases appeared just for the virus to be discovered another year after that, to have a test. And really, it wasn't till 1991 when triple therapy came in combined antiretroviral therapy that actually people with HIV stopped dying because the S T, which was discovered and approved in 1987 on its own, didn't work for Terry look terribly long because resistance was developed quite quickly. I will talk a little bit about, um, the stigma of HIV and how patient's feel it. But you can see that it was only in 2010 that the United States lifted their ban on entry for those with HIV. 69 countries as of last year still criminalized homosexuality. Um, it's only just 13 years ago that life insurance has become available to those with HIV, so there is there are still issues about stigma. If you if that has piqued your interest and you want to read a bit more, the the two on either side are books written by people who were around in the 19 eighties on the West and the East coast of America, and the middle one is a UK TV series which I don't know if you're able to access abroad. But if you can, then I would highly recommend it. So let's meet Jennie. She's 29 your GP in central London, and she's newly registered at your practice. And she's come because she's on the contraceptive pill, so she wants to get a repeat, and she has little asthma. So she's come to get her inhaler sorted, married with a couple of kids and no other medical issues. Now you can't vote, but I'm just asking you to think and what I would. I would replace central London with your nearest major city, um, and have a think about whether you would routinely offered someone an HIV test just on the basis that they had become your patient, newly having moved from another doctor. Um, so the guidelines in the UK is that if you practice in an area of high or extremely high HIV prevalence, so that is two or more cases per 1000 population age 15 to 59. Then you should be offering an HIV test to people who register with you as a as a GP practice. Um, and it should be offered every year. Um, so this is a map of England, obviously. And you can see that you have The high prevalence is in London particularly. And that that one on the south Coast that is brightened where there's a very large LGBT population and then in some other major conservation's, um, around the country. So I guess the international sort of translation of this is that if you live in a major urban city, um, your HR, the background rate of HIV is probably going to be higher than if you live in the countryside. If you live in a city where there is a large LGBT population lesbian, gay, bi sec, transgender. Then again, you are likely to have a higher HIV prevalence prevalence. And probably the one thing that the single most important thing and, um, we can do in primary care and the single most important take home message is that we should probably all be testing more than we are at the moment. These are other sort of public health kind of reasons that you might want to test for HIV. Um so gay men, men who have sex with men, whether they're gay or bisexual, are at a significantly higher risk of HIV than the general population as our trans women. So these are people who are biologically male but identify as female, and they will often have sex with other men, and therefore that puts them in the same risk bracket as biologically male people who identify as male, obviously people who have lots of sexual partners. Um, if a patient discloses to you that they take part in Kem sex, which is the use of drugs such as amphetamines to enhance sexual pleasure, that is a massive red flag for HIV risk. Because Kem sex sessions often go on for days and days and condoms often aren't used obviously victims of sexual assault. Anyone who is concerned enough that they've come and asked for a chlamydia swab should also have an HIV test and transmission through blood. And transplant's and medical procedures is unusual, almost unheard of now in developed countries where there are there are procedures for HIV screening. But if someone has had such a thing in a country where that may not be the case, and obviously if they've had a needle stick injury, then a risk assessment needs to be done. The British HIV Association has a list, and I put the Web link below. If you want to look at it of what they call indicator conditions, so these are conditions, um, that might indicate a higher than average risk of the person having HIV. And I've pulled out here some of the primary care relevant ones. Um, but obviously, um, you know your medical student secondary care is also relevant for you, so you might want to look at the whole guidance. Um, these are things we commonly see in primary care, and we'll also present to a and e um, to emergency department. You know, someone with chronic diarrhea or weight loss or fever of no obvious cause. People with gastrointestinal infections such as salmonella and shigella dementia that should actual. It's a subcortical dementia, which is sort of your vascular dementia rather than your Alzheimer's. But I must say I do taste all my new patient's with symptoms of dementia for HIV because I have seen the occasional case where someone had was bed bound with dementia and someone spotted it that it was actually HIV dementia rather than Alzheimer's and antiretrovirals were transformative. They actually managed to leave the nursing home that they were in and go and live a much normal, much more normal life. If you were in any sort of clinical scenario where you're regularly doing blood tests, things like full blood counts, then you will have these patient's who come back with results that are just a bit outside the normal range. You know, platelets, a tiny bit low neutrophils, maybe 10% below the bottom limit of normal. You're probably not going to do anything about it. You might look back and see that the person has been slightly neutropenic for years, and neutropenia can be associated with certain ethnicities. But when that happens, just think. Has this person ever had an HIV test? And if they haven't then offer it to them. And obviously, if you're having an infection, your patient has an infection that is transmitted in the same way as HIV I, either by sex or blood borne infections such as hepatitis, then that is worth checking for HIV. So cereal conversion cereal conversion is the point at which you catch HIV, so I'm just going to go back to that graph at the beginning. This is the the dip at the beginning. Just when the person has had the infection and the CD four count dips and then comes back up. And during that dip they can be unwell. And obviously we really want to spot HIV. At this point, we really want to pick it up, because it means we can get the person onto antiretrovirals really quickly, and I'll explain on the next slide why that's important. And also, of course, we can stop them transmitting it because if they don't know that they have HIV, then they can't take precautions not to transmit it to their partner. Around half of all patient's will have symptoms within a few weeks of catching HIV. The problem is that these are really nonspecific, and it's probably not practical to offer an HIV test to every single person who presents with a sore throat in the winter. You know, I see so many people speak to so so many people with the sorta, and I usually just sign post them to a pharmacy. I'm not convinced it's practical to offer an HIV test to everyone but the highest predictive value is a fever and this typical macular popular rash. So this is a rash that we would probably look at. And if the patient had symptoms of a respiratory tract infection and they were otherwise, well, we probably you know we might. We'll say this is probably a viral rash and it should go away by itself, and that may be true. But the virus causing the viral rash, maybe HIV. So just look out for this group. You need to be aware of something called the window period if you're offering HIV test to people who may have caught it recently. The early HIV tests used the antibody rather than testing, too, for the antigen HIV itself, and it took about 12 weeks for the body to make enough antibodies for it to be detected. And so we always used to say there is a 12 of week window period. So if I have a negative HIV test today, all that tells me is that 12 weeks ago I didn't have HIV, But if I've had risky sex or something four weeks ago, then I have to repeat the test at least 12 weeks after the episode that I'm concerned about. Now more modern tests are more sensitive, and some of them are joint antigen antibody. So in an HIV clinic where they know what test they're local lab is using, they may be happy. Or a sexual health clinic. They may be happy to say, Actually, our window test is six weeks, but if you you don't know what test your local lab is doing that, it's always sensible to get that test repeated 12 weeks later. So if someone is presenting with Syria conversion and maybe they have an episode where they're concerned, they might have been at risk of catching HIV do the test now. But make sure that they repeat it in the appropriate time frame. So why is it important to test so in the UK? Um, public Health England estimate that about 8% of people who have HIV are not diagnosed. Um, and as I said, the normal CD four count is maybe 800. Or that's sorry, that should say 800 to 1000 cells per millimeter cubed. And if you if you drop 80 per year, two typos on this slide, then you can see that after a number of years, you're going to get down to the point of being immunocompromised. And the most important thing for your mortality and how unwell you're going to be is the how early or late you were diagnosed. So if 350 a CD four count, 350 is quite crucial, that's the point at which we used to start antiretrovirals before they were started at diagnosis. If you're not diagnosed until that point, you have a tenfold increased risk of dying in the first year after diagnose and you lose an average of five years life expectancy. And if you're not diagnosed to your CD, four count has dropped below 100. You lose an average of 10 years life expectancy. And, of course, how many people have been infected by this person when they didn't know they have HIV, so they weren't having necessarily having protected sex. So it's really important that we all think about testing so you offer genuine HIV test. And of course, it comes back positive because this would be a bit of a short, short talk. If not, medical students and doctors were all trained in the principles of breaking bad news, and this is no different to breaking other bad news. You want to find out what the patient knows and what they're expecting. Um, depending on your clinical situation, if you can, it's good to arrange an appointment. So if I pick up a case of HIV, I will ring my local clinic so that when I'm giving the diagnosis to the patient, I can say and you have an appointment with the HIV clinic tomorrow at 10 o'clock or whatever. Now they might want to go to different hospital, or they might not be free tomorrow at 10 o'clock. But at least I've arranged that next step, and then they can change it if they want to. And the key message to people who have been diagnosed with HIV now, some of whom will have been around in the 19 eighties when HIV was a death sentence, is to emphasize that HIV is now a controllable chronic disease, and if treated, it shouldn't affect life expectancy significantly. So Jenny's Children are three and five, and she had them in the UK, where we do routinely do an HIV test at booking in both pregnancies, and both Children are healthy. So just have us think for a second as to whether you think her Children need an HIV test, one of them or both of them or neither of them. So before we come back to Jenny and her particular kid's, we'll talk a bit about HIV testing in Children. Um, there was a case many years ago now, um, couple who had HIV. They didn't want their son tested, and after a while the boy grew up and he was 13 and he had never been tested. And I think all the doctors kind of went well. He's 13, and he's well, so I'm sure he hasn't got HIV. And then one day he got the most awful headache and he went into accident and emergency, and he had, as part of the work up, had an HIV test, which was positive, and his CD four count was was, uh, almost nothing. And he died within 48 hours. I think of toxoplasmosis. Um, and this is the lesson from this is that as we see in other things, Children can be really, really, really fine. And then suddenly they fall off a cliff and get really ill. They've got fantastic reserves, so they appear to be well when they're actually, uh, sort of becoming unwell. So we know that antivirals antiretrovirals reduce um, illness. Even in a symptomatic, Children and Children with HIV should be treated straight away. Um, the transmission is obviously only through the mother, so there's no we know there's no transmission through household contact. And so the question is, the mother can transmit HIV vertically during pregnancy, during delivery or during breastfeeding. So if a mother has had a negative HIV test after her child has been born and she's finished breastfeeding, then that child doesn't need testing because you know that she was HIV negative at the point where she could have transmitted it. So, um, Jenny had tests at pregnancy with both of her Children. So her five year old doesn't need a test because, um, by the time she was pregnant with her three year old, she'd finished breastfeeding. And so her five year old is a no risk. But she has not had a test since you were pregnant with her three year old, so her three year old does need a test and depending on systems locally, usually usually either the HIV consultant for the mother or the pediatricians are happy to get involved and thinking about that. If you work in a system like the UK, where we offer HIV tests to all women at their antenatal clinic, then you should just your antennae should just twitch a little bit. You should be a bit concerns about the cohort of women who refuse that HIV test. There have been some really interesting studies where they did anonymous HIV testing on all women in an anti now clinic, including those who refused, Um, and they found that refusing an HIV test at booking carried quite an increased risk of having HIV. It's something to do with the sort of, you know, denial, not wanting to know you've got it. So in some areas in the UK, all women who refused their antenatal HIV tests are discussed at a multi dinner disciplinary meeting as to whether they need any any support whether they can be persuaded to have the test. Um, in the UK refusal to allow a child to be tested is a child protection issue, which would eventually lead to a court to order for testing, but usually it doesn't get that far. Usually, once you get rapport with a parent, you understand why they need to be tested. Then it's not an issue. Think about other high risk Children, those in care, unaccompanied refugees, as where parentage maybe isn't clear. And they're from an area of high risk for HIV, whether you need to arrange testing for them. So you refer Jenny to an HIV clinic, and she started on antiretrovirals and everything's good. Her CD four count comes up. Her viral load becomes undetectable, which is the benchmark of successful HIV treatment, and 18 months later she wants to have another baby. But her husband doesn't have HIV, and so far they've been using condoms. So question to think about is, is it safe for her to have unprotected sex with her husband without transmitting HIV to him? And the answer, which is slightly counterintuitive? With all we know about HIV being sexually transmitted, the answer is yes. This campaign undetectable equals un transmittable. Um, we know from 2018 that people who have HIV, who have an undetectable viral load for at least six months and are on antiretrovirals cannot transmit HIV. These are very strong statements cannot transmit, Do not transmit. For some years we knew that the risk was lower. But we now know that the that the risk is actually zero. And this is based on large studies with zero discordant couples. That is where one person has HIV and one doesn't and tens of thousands of acts of intercourse unprotected and absolutely no transmission. So this is a real game changer, and it's a big incentive to take antiretrovirals because it means that you know you can have unprotected sex with your your partner or your husband or wife in the same way as everyone else. And also you can try for for a baby in the usual way, without having to involve fertility clinics and so on. Excuse me So HIV prescribing, as I said, everyone now gets antiretrovirals from diagnosis. And in the UK, HIV clinics will always right to the GP. We have had an issue certainly in the UK, with some patient's refusing, um, to let their GpB informed, and our consultants in the UK and are very proactive about wanting their primary care that the patient's primary care doctor to be involved unless the patient actually refuses. Obviously, there are different health systems in different countries. Um, the main issue with antiretrovirals is that some of them are cytochrome p 4 50 inhibitors, so they can have, um, interactions with other medications. So if you're working somewhere where you have a computer system that picks up drug interactions, then it's important that you put these medicines on the screen, even if you're not prescribing them. This is the Liverpool drug Interactions website, which is what the consultants use. So I'm not sure if you can see that the sort of reading, But basically I've put in here an HIV drug and another drug that interacts, and you can see you're getting a big red do not prescribe. And then here are some drugs that don't interact, and you get a nice screen absolutely fine to prescribe. And this is what it looks like in the UK If you put hospital issue drugs such as anti retrovirals on the computer screen, uh, HIV drugs can potentiates steroids, including those which are inhaled or given us joint injections. So just be aware of that other small risk of Cushing's um in the in the old days, um, in the UK In some areas, people with HIV weren't entitled to a fertility referral because it was felt that the risk of transmitting HIV to the child was too great and that the parents were probably going to die young. Um, that is obviously all changed. HIV is a chronic controllable disease, and we know that transmission vertical transmission with good care is as close to zero as it's possible to be, um, talks I have heard from obstetricians who deal with patient's with HIV have said that they have gone, you know, many years without a case, and the only cases they have had to have been patient's who didn't get the proper care because either they didn't turn up for appointments or they got lost to follow up. Or they had immigration all housing issues, which meant that they couldn't probably be treated. Um, if the patient, the partner with HIV in a discordant couple, doesn't have an undetectable viral load. So whatever reason, they're not taking their antiretrovirals. If that cup partner is the man, then the the A couple who want to conceive can use sperm washing because There is no HIV in sperm, but there is HIV in the seminal fluids so they can have sperm washing and then intrauterine insemination. If the partner with HIV is the woman, then they can have home insemination with a syringe in and some sperm. But obviously by far, the better option is that the partner gets their viral load undetected, and then they can just try and conceive in the usual way. Um, the advice in the UK is not to breastfeed if you have HIV. This is not the same advice worldwide because obviously you have to look at the overall risk to the baby. And if you are an air area where there is no access to clean water, then the risk to the baby of, uh, gastroenterology, gastrointestinal infections and so on and potentially death maybe greater from formula than the risk of vertical transmission from breastfeeding. But in the UK and in other developed countries, the advice is to breast is not to breastfeed. Breastfeeding is really important to some women. Um, in some cultures, if you're not breastfeeding, that is looked very suspiciously, it might even sort of give away to other people that you have HIV, and you may not want them to know that. So if a woman in the UK is absolutely desperate to breastfeed, then they can do that. But there are protocols with sort of regular testing, um, advice not to breastfeed if you have cracked nipples. For example, if the baby has a stomach infection, we would consider that in a developed country that breastfeeding without engagement with those, um, those things to reduce the risk of vertical transmission is a child protection issue. Um, as you probably know, the foetus has no rights, so you cannot force a pregnant woman to do anything to protect the foetus, such as take anti retrovirals during pregnancy or have a Caesarean. But once the baby is out, then they have rights, and if they are being put at risk, then that is a child protection issue. So Jenny's 12 weeks postnatal her last year was 18 months ago in the UK We do smears every three years up to the age of 50 and then every five years. Um, the reason for that being that the changes you see on a smear test take many years to become cancerous. Um you know, over 10 years. So there's really no real medical or scientific basis for doing smears every year on everyone, as is done in in some countries. Um, but when does she need her next smear? So is it given her HIV? Is it due now, or can she have it in 18 months time, which will be the normal three yearly thing? So we know that women with HIV have a higher prevalence of the nasty forms of sorry. That should say HPV the oncogenic forms of HPV. And they have a higher prevalence of, um c i n um, and the the pre cancerous changes and of cervical cancer. And so they should all have a colposcopy at diagnosis and annual smears until age of 65 even if they're all normal. And this is sometimes done by the G p and sometimes done in general practice. Some women with HIV won't want to get pregnant, and we want want contraception. Um, HIV itself, as an illness is usually not a contra indication to any contraceptives. Um, the only, um, the only exception to this is putting in an intrauterine device a coil. Um, if the CD four count is less than 200. This becomes UK MEC three, which means it is a relative contra indication. And on balance for most women, the risks will outweigh the benefits. I assume this is because there is an increased risk of P i D. Of pelvic inflammatory disease and infection, pelvic infection at the time of fitting. And obviously, if you are immunocompromised, then this isn't a good thing. It doesn't mean that having the coil in itself is a bad thing. So if you diagnose, uh, if someone has a late diagnosis of HIV with the CD four count less than 200 they already have a coil in place, there's absolutely no reason to remove it. This just applies to new fittings. Um, the issue with contraception is that many antiretrovirals, as I've said, are enzyme inducing. And so things like the pill might not work because of the interaction. So they may need an intrauterine device or a depot, and if you're giving them an emergency contraception, then they should have a double dose of levonorgestrel or, ideally, a copper coil, which is the safest form of that Sorry, the most efficacious form of emergency contraception, the for most likely to work, but it is often refused, and if it is refused to give a double dose of oral emergency contraception of Leven gestural, this has been another game changer along with Along with you equals you. Um So the Proud Shirt study showed that for people who are HIV negative, but they are at a high risk of transmission because, for example, they have unprotected sex with lots of different people. If they take an anti retroviral either daily or on demand just at the time of unprotected sex, their risk of transmission is significantly reduced, so the number needed to treat is only 13. Treat the 13 people with this pre exposure prophylaxis, and you will save one case of HIV, and that's massive. You think? Oh, that's a bit rubbish for the other 12, but if you think about other things that we do for Patient's for primary prevention, like statins for Primary prevention of heart disease, the number needed to treat with a statin to prevent a heart attack or a stroke is in the hundreds, maybe 2 to 300. So an N. N. T. Of 13 is pretty good in the UK it's available from Gu clinics. Sexual health clinics. Um, and obviously, depending on the health system where you live, will depend where your patient's can get it from. It's usually reasonably well tolerated. People sometimes get headaches and tiredness, and they need to have their kidney function checked at least once a year or more often if they have problems with their kidneys. Some of you may have had post exposure prophylaxis if you've had a needle stick on clinical rotation or something. Um, the idea is that again you take a month's worth of antiretrovirals and it stops you Sierra. Converting the key thing is to get the first tablet in as quick as possible. So it's rush, rush, rush, get some baseline bloods done first tablet in, and then everyone can sort of calm down there, taken twice a day for a month. And in the UK it's usually access through occupational health or through the emergency department. And you can see from this table that if you are thinking about pep for a sexual exposure rather than for a workplace exposure, then there are lots of situations in which the risk is so low that it's not recommended. So it's really only recommended for sex if the person has HIV with a viral er that is, um, detectable or unknown, or if there is a high re, reasonably high risk that they have undiagnosed HIV. So back to Jenny. She's 46 she's going through the menopause and her HIV is still well controlled. She's got no other medical history apart from her ongoing mild asthma, and she's come to the GP to ask for HRT hormone replacement therapy for her menopause. So this is this is kind of a new issue. In the early days of HIV, Um, no one was thinking about the needs of older people with HIV because to be quite blunt, people with HIV didn't get old. They died. And so this wasn't an issue. And you can see from this graph that the number of people in the age that for women is the menopausal age is growing significantly, and there there is a smaller number of people who are even older that is also growing. So this is going to be a real issue in your careers as we have a cohort of older people with HIV and this prime study looked at HIV at the menopause. They did questionnaires to patient and GPS. And what they found is that 95% of GPS that were asked We're confident to manage the menopause in an average woman without HIV. Um, slightly worried about the other 5% because this is definitely a primary care thing. But anyway, but when the patient had HIV, the number of GPS who were confident to manage the menopause dropped to 46%. And this is not because they were discriminating or they didn't want to look after these patient's or anything. But they had reasonable concerns. They had concerns about drug interactions, worried about missing an HIV related diagnosis. You know, I I might treat this woman with with HIV for her with HRT for her night sweats, but she has she actually got an in foma or something, and they didn't know about the risks. And the problem is that these women were getting bounced back and forwards between primary care and their HIV consultant. So the GP was saying, Well, I'm a bit worried about starting you on HRT. Go and talk to your HIV consultant me HIV consultant, was quite recently reasonably saying, I only do HIV. This is well outside of my skill set. Go back to your GP, um, and you can see at the top there they actually had quite significant amounts of menopausal symptoms. So the take home message is that HRT is safe in women with HIV, you may have the same interaction issues in terms of drugs that, uh, mess around with the liver enzymes, and so sometimes you might have to use higher doses. And, if in doubt, speak to the women's HIV consultant. HIV consultants are kind of like us. They are generalists because HIV affects everybody system and they usually know their patients' really well. They never discharge them, and they're always happy to talk to the GP. And then what about the wider issues to do with HIV and aging, which, as I say, is a sort of relatively new concept? Life expectancy is similar to if you didn't have HIV as long as you've got on your antiretrovirals reasonably earlier. But we do know that there are people with HIV have a lower number of healthy years. So in March 2020 there was a big cohort study presented, which had been gathering information for 16 years from 2000 to 2016. And they looked at 39,000 patient's with HIV and 390,000 matched adults without HIV. And they found that the gap in life expectancy narrowed. So in 2000, when they started the study, it was 20 years, and in 2016 it was three years. But the people with HIV had 16 fewer healthy years, and on average, they got their co morbidity 16 years earlier. So you just need to be aware of HIV. There's a risk factor for frailty. Why? Well, I'm not sure. 100%. No, there is research going on about it, but there are probably lots of reasons partly to do with sort of chronic inflammation. Chronic infection. Lots of inflammatory markers remain raised, um uh, in HIV, even when it's treated. And some of these have independent associations with things like low muscle mass, which can lead to frailty and poor physical function. Um, there are, of course, Confounder is So, for example, a patient with HIV will probably have the HBA one C checked every year at their HIV clinic. Um and so the minute they tip over into the diabetes range, they will know about it. Whereas you or I might not bother to go and get our HBA one c checked at all so we might have diabetes and not know about it. Um, the it's important to think about when your patient was diagnosed. So if you're diagnosed with HIV today, then you will be put on, uh, probably a combination antiretroviral. It may be as simple as one tablet once a day, so very easy to remember, and it's relatively side effect free. If, if you were diagnosed in the 19 nineties, you were started on a cocktail, that might mean you had to take six tablets four times a day, and some of them had quite nasty and irreversible side effects things like peripheral neuropathy, which can affect mobility and significant increases in lipids, which gives the risk of cardiovascular disease. So that's relevant to think about. So in summary, Um, test. If you take one thing away from this talk, do more HIV test. However many you're doing now do more, um, in the UK and in other countries. Obviously, covid has caused real problems, and we are finding patient's have been lost to follow up at their hospital clinics. So just be alert to that, um, and encourage communication between primary and secondary care. Look at frailty. Think about frailty. For older adults. Manage polypharmacy to try and reduce interactions. Promote healthy life in other ways. Exercise diet. Don't be afraid to manage the menopause in HIV and make sure that your women with HIV get annual smears and that is it. So I will stop share ing, and I'm happy to take any questions just before we take some questions. Just guys. Just to remind you, Um, the link for feedback has been posted in the chat. Just make sure you're giving us feedback so you can continue to offer these lectures. Um, and also it's very important to do this so you can get your certificate as well. If you have any questions for the doctor, just put it in the chat, or you can on mute if you'd like to, but just one at a time, if you can. Yeah, and I really encourage you to give that feedback. It is useful to know if these are at the right level. I think a lot of us are using talks that we have previously delivered to doctors. And if they're at two higher level, then we need to know so we can adapt future talks. And if they are useful and at the right level, then also that's nice to know it gives us a warm, fuzzy feeling, if you don't mind. Doctor, I've got a question for you, Uh, myself, uh, with antivirals and HIV medications, Uh, I find it very difficult when people come to say by medications or they come to get prescribe something because you have to go through each single SPC for the interactions. Are there any resources? Um, they can easily check interactions for him. Um, so obviously, if you have a computerized system, then that may come up with them. But if not, then that Liverpool drug Interactions website. I think you can put in more than one antiretroviral and more than one other drug at the same time, and it will look at all of them. Um, and that is the resource that that HIV consultants in the UK you so it's a very safe resource to use Perfect thank you, doctor stunned everyone into silence. I know there's some difficulties with Internet people might not. Might be having difficulty, um, putting questions in the chat guys, you cannon mute as well. Um, if it's difficult to to type any questions, just a mute and you can answer Dr directly. One thing I will say which I'm touched on at the beginning of the lecture, but I didn't say more, is, um, some of my patient's with HIV have had huge stigma. And so if your patient's with HIV seem to be overly concerned about their confidentiality, then they may need a lot of reassurance, and they may have good reason to. I had a a patient who had a cesarean for her HIV to reduce vertical transmission, and one of the midwives put a bio has a tape in a big sort of cross Allah sort of CSI or something on the TV across the door of the theater. And I had another patient who was at a hospital where they used paper notes. She was there, actually for something else, not for her HIV, and the nurse picked up her notes and sort of held them kind of in front of her like that and called her. And she could see from the back of the waiting room that her notes had written on them in big, thick marker pen HIV and a plus sign that she could read. So basically, everyone in that waiting room knew she had HIV. I hope things are better now. You know, I think I think some of the stigma has reduced with it being treatable and so on. But, um, your patient's with HIV, particularly if they've been diagnosed a long time ago, will have really interesting stories to tell. And if you have the time, it's it's worth listening to them. Thank you so much, Doctor. So we're just waiting on a few more people to feed back to us. Uh, still no questions, But if you don't mind, I've got another question for you. Yes, of course. So, when you when you you mentioned about keeping the viral load load? Uh, they can all like I can have tentacles with, like, a husband and wife, etcetera. But how do you know the viral load is low? What they're testing. How often do you have to test like to touch. Yeah, so it depends. So HIV clinics Usually when they start someone on antiretrovirals, they will keep quite a close eye on their viral load. They might test it every sort of six weeks or three months, and then once the person is stable for a while, they'll extend that. And people have been on antiretrovirals for a year and are completely stable. Might have their viral there tested just once a year and be comfortable with that. So it's a It's a gradual thing of extending the time between testing, as you can tell, that the person is more stable. Um, and and it doesn't I think an undetectable viral load is defined. I think it's a viral load below 200. You can get blips within that, so I'll just answer that question. Actually, viral load and CD four count of two different things. So the viral load is the amount of virus in the blood, so you want that to be low. Undetectable is usually considered 200. I can't remember the unit copies per something or other maybe copies per mil. Um, but within that you can have blips. So if you have a very sensitive test that measures down to say 50 or 20. If someone's viral load is 21 day and it's 30 the next, that's still undetectable. So you the viral load, you want to be low? Um, the CD four count is your white cells, your protective white cells. So you want that to be high. And so a patient who is doing well on their HIV treatment will have an undetectable viral load and a CD four count, maybe in the sort of 700 or eight hundreds. Um, that's the sort of thing you want to see. We've got another question for you. Um, so how often the affected person should test once the person has been person has undetectable viral load and they should continue their retrovirals. So, basically, should they continue their retrovirals if their viral load yes, absolutely. Antiretrovirals are only suppressing the disease, and at the moment you need to continue them for life. You stop them that your viral load will come up. Um, we don't know. Obviously, if in the future there will be a cure, but But I don't think we're anywhere particularly close to them. And as I said, people with stable HIV will often have their viral load check just every six months or or a year. But early on, when they're just starting on them, then they will test much more often to make sure that they're working because, um, HIV can develop resistance. Um uh, A similar way to sort of antibiotic resistance. So if you catch your HIV may be from someone who has taken antiretrovirals but not taken them regularly, then you might have caught a resistance strain. And so the first antiretrovirals, the clinic, if you might not work. And so that's why they keep a close eye on the viral load early on and then once they're happy that it's working. The viral load has been suppressed for a while. Then they can stretch out the time between tests. I should say that in some countries, in some lower resource countries, there is now money for anti retrovirals, but not necessarily the money for the testing. So in some, in some places it's a bit more. Um, it's basically done on symptoms, you know, everyone gets the antiretrovirals, and if you get better clinically, then fine. And if you don't then there might be the money for testing. But in developed countries, testing is done regularly, often when you start your antiretrovirals and then less often once you're stable. So there's just another question. So from Lola, So basically, the lower amount of virus, the higher the CD four. Yes, so so the virus suppresses your CD. Four. Count your CD four cells so as you then take anti retrovirals to to keep the viral load suppressed. That allows your CD four count to climb up. So if you have someone who, for example, was diagnosed quite late and they're see, the four counter diagnosis was maybe down to 200 or something, and you treat them. What you'll see is, first, you'll see the viral load being suppressed. But the CD four count will stay low and then, after the viral load has been suppressed for a while, the CD four count will gradually start to rise, and generally 200 is sort of considered 200 for the CD. Four count is considered to be the point below, which you're immunocompromised. Um, you want to get people above that and below 200 consultants might do things like give prophylactic antibiotics against Pneumocystis, which is a chest infection you can get with HIV. That that's all of thing. And in Covid, um, the boundaries for which patient's with HIV should be shielding were considered to be very immune. Suppressed were to do with their CD four count at the time and also how low their CD four count has been in the past. How is vertical transmission? Pretend prevented during delivery. So in the early days, um, it was basically everyone was offered a cesarean. Um so in in the early days, it was antiretrovirals for the mum during pregnancy, even if she wasn't having them for her own care, because at that time not everyone was being given them straightaway. Cesarean know breastfeeding, and the baby gets antiretrovirals after delivery. Um, now that we have more experience with this, um, then we can for women who want to attempt to have a normal delivery. Then obstetricians will go along with that, Um, but they take great care and they put sort of parameters on it. So, for example, I'm not an obstetrician, but I think once the waters break, they want that baby out within a few hours, and if not, then they will revert to a cesarean, obviously with the mother's consent. Um, you talked about hemorrhage and cuts in the birth canal, so you know you would want to reduce the risk of that so you wouldn't, for example, do fetal scalp monitoring where you put something on the fetuses scalp because obviously that causes risk of transmission. And I think I think a vaginal delivery is still higher risk than necessary in. But obviously women will have their preferences. And we have to respect that, and particularly if you if you think you're going to have lots of Children, then obviously there are risks associated with having multiple cesarean sections in terms of adhesions. So if someone's having their first baby and they think they want four or five kids, and I can understand why they might want to go for a try for a vaginal delivery, um, the chances of giving birth to a healthy child if the mother is sick and being treated. If the mother has proper obstetric care with with all these things in place and she doesn't breastfeed, also the risk of vertical transmission is it's as close to nothing as it can be. So the last presentation I saw about this was some time ago. It was maybe 10 years ago. Now, from I think it was King's Hospital and they presented three years' worth of data. They were a massive center loads and loads of patient's, and they only had one case of vertical transmission. And, um, that case was in a woman who had not adhered to therapy. She had a very complicated social situation moved around A lot. Haven't taken the antiretrovirals, so I don't think you can quite say transmission risk is zero, but it's pretty close. Just have another question for you, Doctor, from just in regards to patient confidentiality if HIV and is on treatment. But their partner is unaware. As a doctor, how do you protect their partner? So this is really interesting. So before you equals you, Um, certainly in this country that GM see guidance would have been that actually, the duty of our duty of care to the partner probably outweighs the duty of care to the patient, to keep their confidentiality in the same way that you wouldn't keep the confidentiality of someone with epilepsy who was continued to drive. And so if I couldn't persuade the patient to tell their partner and if the partner was registered with me as well, then I probably would have eventually have told them, Um, but with you equals new you. Now we now know that obviously, if the viral load is under undetectable and has been for six months and the person's on treatment, there is no risk of transmission. So I don't think you could justify breaking confidentiality there has in the past before you equals you. They've been legal cases where people have been committed of things like, um uh, convicting of things like actual bodily harm, gross bodily harm for knowingly transmitting HIV. But I think we will see a lot less of that because of you equals you. How do you treat HIV and newborn babies? I'm not a neonatologist, but I think you use antiretrovirals. Certainly, last time I looked into it, it was as t which I think can come in liquid form. Um, and so there's there's the prevention. I think they get it for six or eight weeks or so after they're born. And then, obviously, for those babies who have contracted HIV virtual vertically. Then they would need to go and have specialist care from a pediatrician. Lovely. Thank you so much, Doctor. So we have another lecture coming up back to back. Thank you so much. No problem was great. Thanks, everyone. Bye, guys. And again, Thank you, guys. I'm gonna stay on for just a minute. Just let you get the certificate. Make sure you do, Uh, follow us on the next, uh, the next lecture. I'm just gonna pose the certificate and I'll pop in. Okay, It's already in the chat. So it's lecture number two. It's gonna be pediatrics by Dr Caroline. Um, it does say Doctor Delahunty Delahunty, but it's a It's a different doctor offering the lecture. Uh, so just a minute on that, if there's any issues of you can always email, uh, the email that I've put in the chat as well. If there's any issues for the certificate. All right, guys. We'll see you soon. Thank you.