HIV care has changed – and will have to change some more

There were 10,000 people living with HIV in 2000. Today there are around 100,000.

HIV remains to be the fastest growing long-term condition in the country, yet we have not had a single national campaign led by the government since the 1980s when the epidemic began. In 1948, the then Minister for Health, Aneurin Bevin, probably never envisaged such a catastrophic infection to hit the nation, in the name of HIV – the original NHS was never designed for such a unique infection that had the ability to end lives prematurely and be able to affect anyone who was at risk of acquisition.

As HIV was never in the overall NHS plan in the 1980s, no one really knew where it should sit, hence HIV wasn't originally looked after by the same specialty in each NHS trust. HIV now firmly sits with the genitourinary medicine specialty and we believe this is best place for it given the uniqueness in the stigma associated with it – quite possibly in parallel with the stigma that exists around poor sexual health.

At first HIV was palliatively treated with many people dying of the natural progression of the infection - fast forward ten years to 1996 when we started to see the first anti-retroviral therapy (ART) medications prescribed. This form of treatment has continued until today with many (if not all) patients living with the prospect of a happy, healthy, long lives.

An aging population
ARTs are not just being offered to people living with HIV, they are also offered in the form of PEP (post exposure prophylaxis) for those who have been at risk of acquiring the virus within the last 72 hours and most recently in the form of PrEP.  PrEP is a pre-exposure prophylaxis to HIV that is currently being trialled in the UK (The Proud Study) to gay and bisexual men and those at high risk and struggle for whatever reason to use condoms consistently. The PROUD study has recently released preliminary findings, which so far are promising, as well as having prevented many within the study from acquiring HIV. Although the approach is controversial in bo medical, nursing and wider healthcare communities as well as the gay community. Whether you agree or disagree, it will most likely be offered on the NHS before too long.

While HIV isn't a death sentence anymore, there are many challenges with HIV, including co-infection with Hepatitis C, managing people who are HIV negative who are sexually active and/or in a relationship with someone who HIV (serodiscondance) and the increasing street and party drugs scene which often lower inhibitions and facilitate unsafe sex.

Probably the biggest challenge ahead of us is the public health agenda on aging and HIV and is something all specialties will begin to see in their services and practices. It will impact on the perceptions of ageing as well as older people’s needs of care too. This needs to be considered by frontline services and commissioners need to start thinking about and collaborating within the wider public health field.

Innovative projects
The 56 Dean Street clinic is a leader in the sexual health and HIV field and has a unique ability to develop creative ways of engaging with communities affected by HIV, such as offering weekly sexual health screening in public sex venues (such as gay saunas), the award-winning CliniQ (a specialist sexual health and wellbeing clinic provided in partnership with trans* people for trans* people), gay social venues (such as G-A-Y bar in Soho once a week), specialist street and party drugs (namely, chemsex) support from a leading expert (@davidastuart on twitter), as well as, using social media as an outlet to directly give health promotion messages to internet savvy clientele.

This February, we opened Dean Street Express, the world’s first walk-in clinic to offer rapid PCR chlamydia and gonorrhea testing on site. This has created an extremely convenient and quick routine sexual health check up which includes instant HIV results and all other results via SMS within six hours. The service has begun to tackle head-on the many challenges faced by sexual health services across the country (and probably the world) through normalising and making testing easier (all self-swabs!) and reducing infection rates by cutting down the time between testing and treatment. On the first day of opening Dean Street Express, we tested a patient at 12 noon and they were diagnosed and treated for chlamydia by 4pm the same day. Some patients may have many partners while waiting for test results.

Key messages for your patients:

• HIV doesn’t require hype to risk. It requires logic to risk. This could be one way of normalising the process and routine of testing for it. If you take a lot of risks, test every three months, if you don’t, test once a year.
• Fear tactics in health promotion to HIV are not ideal – they create unnecessary anxiety and increase stigma to those testing and those who live with the infection.
• The earlier the diagnosis, the better the prognosis.
• Being HIV positive has legal implications as well as further health complications such as co-infections with hepatitis C.
• Respond to your local community health needs. In London we have big public health issues with gay and bisexual men having lots of unsafe sex while under the influence of street and party drugs (often referred to as ‘chemsex’ – more information here)
• Use the language your communities use. Don’t alienate with clinical language – such as using ‘barebacking’ as opposed to ‘unprotected anal intercourse’.

About the authors

Michael Fanner is a bank staff nurse at 56 Dean Street and a full-time doctoral researcher within the Sexual Health Research and Practice Group at the University of Greenwich
Jake Jenkins is the lead nurse for LGBT Services at 56 Dean Street