FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

Posters

HIV – Poster Nos. 068-077

068
A case note review of chronic lung disease in patients with perinatally acquired HIV in the UK

Abstract - 068

Poster 068

A case note review of chronic lung disease in patients with perinatally acquired HIV in the UK

Penny Ellis1, Paul Collini2,3, Fiona Shackley4, Kelechi Ugonna4
1University of Sheffield Medical School. 2Academic Directorate of Communicable Diseases, Sheffield Teaching Hospitals NHS Foundation Trust. 3Florey Institute and IICD, University of Sheffield. 4Sheffield Children’s NHS Foundation Trust

Introduction: ART treated HIV-seropositive individuals are at an increased risk of chronic co-morbidities associated with ageing. A greater prevalence of chronic lung disease (CLD) is also recognised. Reports from sub-Saharan Africa describe an increase in CLD in children and adolescents with perinatally acquired HIV. As well as residual HIV viremia, chronic inflammation and immune activation it is thought that local factors play a role in the pathogenesis of HIV associated CLD. Postulated factors include delayed diagnosis of HIV and ART initiation, the high burden of respiratory tract infections and harmful environmental factors, such as household air pollution. Thus, such findings may not be generalisable to those with perinatally acquired HIV in the UK. Initial data in children and adolescents in high-income countries indicate there may be a higher than expected prevalence of obstructive CLD. We set out to determine the prevalence and phenotype of CLD in those with perinatally acquired HIV in the UK.

Methods: A retrospective case note review of 82 children and young adults with perinatally acquired HIV. Data were extracted from clinical records to describe respiratory diagnoses, symptoms and chest radiology findings at 5 paediatric or transition HIV clinics in the North of England. 

Results: 82 perinatally acquired HIV-seropositive individuals were included in the case note review. Median age was 18.5, (IQR 15.0-22.0) and 50.6% were female. 68.3% of individuals were of Black African ethnicity and 73.0% were born outside the UK. Median age at HIV diagnosis was 5.1 (IQR 2.0-10.7) and median number of years from HIV diagnosis to ART initiation, was 0.2 (IQR 0.0-3.0). The most prevalent abnormalities on 80 who had available chest radiography were ring/tramline opacities 21.1% (20) and consolidation 13.7% (12). The most prevalent abnormality on the 10 who had high resolution computed tomography was bronchiectasis (3), 30.0%. The most prevalent diagnoses of lung disease were bronchiectasis (6) and community acquired pneumonia (6), each 7.3%. Individuals with a diagnosis of bronchiectasis were significantly more likely to have had outpatient respiratory tract infections (10.5 [IQR 5.3-18.0]) compared to individuals without a diagnosis of bronchiectasis (2 [IQR1.0-4.0]), 95% CI -22 to -1, p=0.026.

Discussion: There is an increased prevalence of bronchiectasis in this sample of perinatally acquired HIV-seropositive children and adolescents in the UK, and it is associated with more frequent respiratory tract infection. The prevalence is similar to that reported in the USA, 5.7-14.9% but not as high as sub-Saharan Africa, 33-43%, potentially reflecting differences in risk factor exposure. Similarly, ring or tramline opacities were often seen on CXR in this cohort, albeit at a lower frequency compared with that seen in prospective studies in sub-Saharan Africa. The results of this retrospective study demonstrate that there could be a higher prevalence of bronchiectasis in children and young adults with perinatally acquired HIV in the UK than expected. It is now necessary to conduct a prospective study to establish the phenotype and prevalence of CLD in the UK population with perinatally acquired HIV.

069
Outcomes for young people with perinatally acquired HIV infection following transition from paediatric to adult services

Abstract - 069

Poster 069

Outcomes for young people with perinatally acquired HIV infection following transition from paediatric to adult services

Penny Ellis1, Fiona Shackley2, Julia Greig3, Claire Ryan4
1University of Sheffield Medical School. 2The Sheffield Children’s NHS Foundation Trust. 3Sheffield Teaching Hospitals NHS Foundation Trust. 4Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

Introduction: In 2011, a joint clinic for HIV seropositive young people was established by staff from the Sheffield Teaching Hospitals NHS Trust (STH) and the Sheffield Children’s Hospital NHS Trust (SCH). Transition from paediatric to adult services can be a difficult time for HIV seropositive adolescents, with some disengaging from care and discontinuing antiretroviral therapy. This study examined how young people managed after moving on from transition clinic to adult services.

Methods: The review included patients who had attended transition clinic since the clinic began and subsequently attended adult services in South Yorkshire. Data was extracted from 11 patients’ e-records and paper notes between February and June 2018. Information recorded included viral load and CD4 cell count results, number of appointments attended, treatment history, pregnancies and education and employment status. 

Results: 11 patients were identified who had transitioned to adult services within the South Yorkshire HIV network. The majority of patients are engaged in care as defined by the BHIVA standards of care (95% of patients should have a viral load <50 copies/mL measured in the last 6 months and attended a clinic in the last 12 months). 10 patients (91%) had attended a clinic appointment in the last 12 months. 10 (91%) patients had had a viral load measured in the last 6 months and of these 9 (82%) had an undetectable viral load. Over 30% of clinic appointments were not attended. 7 (64%) were in full time education. None had a full-time job, but 3 (27%) were in part time employment. There were no pregnancies were recorded.

Discussion: Overall the majority of these patients remain in care following transition to adult services and are adherent to HIV therapy. However, there are a large number of missed appointments and some documented social problems.

The PENTA guidelines, for HIV positive children under 16 years old, recommend that clinic appointments are booked after school hours or during the school holidays to minimise disruption to education and young people should have clinic appointments every 3-4 months. The continuation of this guidance for young adults may improve the relationship with adult services, address the barriers to attendance and promote attendance. It is important that adult services remain flexible to make it as easy as possible for young people to attend clinic appointments and manage their infection. Qualitative research is indicated to determine why patients do not attend their clinic appointment and what young people feel they need from the service.

070
An 11 year-audit on newly diagnosed HIV patients in Newcastle (2007-2017): trends in late presentation and missed opportunities

Abstract - 070

Poster 070

An 11 year-audit on newly diagnosed HIV patients in Newcastle (2007-2017): trends in late presentation and missed opportunities

Han Hua Lim1,2, Joti Ahir3, Edmund L C Ong4,3
1Infectious Disease Unit, Hospital Umum Sarawak, Kuching, Malaysia. 2 Infectious Disease and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust. 3Newcastle University. 4Infectious Disease and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust

Introduction: Late presentation of HIV has been associated with worse clinical outcome for patients, increased cost of treatment as well as increased risk of transmission in the community. In the North East region, the percentage of the late presenter among newly diagnosed HIV patients in 2016 is 46.7%, which is among the highest in UK. An audit was undertaken on the newly diagnosed HIV cases reviewed in our Infectious Disease (ID) clinic at Royal Victoria Infirmary and Newcroft Genito-Urinary Medicine (GUM) Clinic to identify the trend of late presenters and possible missed opportunities for early diagnosis via indicator condition testing.

Methods: This is a retrospective case note and database record review of the newly diagnosed HIV patients diagnosed at Infectious Disease Unit at RVI and Newcroft GUM clinic diagnosed from 2007 to 2017. Late presenter is defined as patient presenting with CD4 T-cell count below 350 cells/mm³ or presenting with AIDS-defining event regardless of CD4 count. Previous indicator condition is defined as those outlined in BHIVA UK HIV testing 2008 guidelines and NICE HIV Testing 2017 Quality Standard as indication for offering HIV test, but was not performed.

Results: Overall, the total number of newly-diagnosed HIV cases (2007-2017) is 510 cases (mean age: 25, range 19-81) where the majority are diagnosed at ID Unit (58%; 297). 65% (332) of patients are of White British ethnicity and male patients constitute 80% (408) of patients. From 2007 to 2017, homosexual transmission was seen in 77% (165) of all patients diagnosed in GUM clinic and 35% (105) of patients in ID clinic. The average median CD4 upon diagnosis for the newly diagnosed HIV patients has increased from 274 in 2007 to 420 in 2017. However, the median CD4 on diagnosis (2007-2017) for patients in ID unit remains low at 232 (0-1442), compared to 437 (15-1180) for patient in GUM clinic. From 2007 to 2017, the percentage of late presenters among the newly diagnosed HIV patients diagnosed is 54%. On average, a higher proportion of ID clinic patients are late presenters (69%) compared to GUM clinic (39%). Since 2007, an average 40% of patients have previous indicator condition documented prior to the diagnosis of HIV in a yearly basis, before it declined to an average of 15% annually from 2015 onwards. For the review of 2017, there are 34 newly diagnosed HIV cases recorded in total, mostly from ID clinic (25; 74%). 61% (18) of them are homosexual transmission and 82% (27) are male patients. Overall, half of all patients (17) were late presenters. Late presenters were more likely among heterosexuals (64%; 9) compared to homosexuals (44%; 8). 6(24%) patients from ID clinic have previous indicator condition documented compared to 1(11%) from GUM clinic.

Discussion: Despite the introduction of BHIVA 2008/NICE 2017 guidelines, the number of late presenters have remained consistently high in our cohort. In 2017, our data showed higher percentage of late presenter from heterosexual transmission group compared to homosexuals. This may be partly due to targeted campaigns aimed at regular testing among the high risk homosexual population. Our previous clinical indicator rate may not reflect the true number due to restricted audit within NUTH setting, as compared to the UK national audit conducted in 2016 which showed 30% of cases having missed opportunities for earlier diagnosis. In conclusion, a comprehensive and structured retrospective audit framework of all HIV late presenters should be formulated to identify and address key areas of missed opportunities in different healthcare setting.

071
HIV testing in primary care in Newcastle: are we doing enough?

Abstract - 071

Poster 071

HIV testing in primary care in Newcastle: are we doing enough?

Han Hua Lim1,2, Kirsty Foster3, Edmund L C Ong4,2, Brendan A I Payne2,4
1Infectious Disease Unit, Hospital Umum Sarawak, Kuching, Malaysia. 2Infection and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust. 3Public Health England North East, Newcastle upon Tyne. 4Newcastle University

Introduction: The proportion new HIV diagnoses which are classed as ‘late’ has improved in recent years, but Northeast England remains the region with the highest proportion of late presenters. Ten years ago (2008), National (DH) guidance recommended increases in HIV testing in high prevalence settings (>2 per 1000 population (0.2%) aged 15-59), including in primary care. In the Northeast region, Newcastle-upon-Tyne is the only local authority classified as having a high HIV prevalence. Our aims were to determine if primary care HIV testing has increased over the last decade and whether testing behaviours are influenced by local HIV prevalence.

Methods: We performed a search of our laboratory records for all HIV tests on persons aged 15-59 years, originating from GPs in the Newcastle-upon-Tyne area (30 practices, c.200,000 patients). We compared data from 2007 (prior to DH guidance) and 2017. We combined these data with practice list size data (from NHSBSA), and with diagnosed HIV prevalence data (from PHE, by MSOA). Antenatal HIV screens were excluded. All testing rates are stated per 10,000 population.

Results: The overall rate of testing increased from 26.0 in 2007 to 44.5 in 2017 (p <0.01). 24 of 30 individual practices (80%) showed an increase in testing rate over this period. Overall test positivity in 2017 was 0.22%. 10 of 30 practices (comprising 46.4% of the patient population) are in high-prevalence MSOA. Current testing rates are slightly higher in high-prevalence than low-prevalence practices (47.8 vs. 41.6, p 0.04). However, rates varied widely (almost 20-fold) between individual practices (median 35.8, IQR 21.6-57.6, range 8.8-168.5) and there was no significant correlation between local HIV prevalence and testing rates (Spearman ρ 0.16, p 0.4).

Discussion: Nationally, the proportion of HIV diagnoses made in a GP setting has increased significantly between 2005 (3.9%) and 2014 (8.1%). Currently (2016), the national GP HIV testing rate is 44 per 10,000 population for high prevalence areas. This is in keeping with our local data. However, we see wide inter-practice variation in testing rates (which is not captured in national data), and this is largely not explained by differences in known local HIV prevalence. In the 2016 BHIVA audit on late presenters, 60% of patients have history of engagement with their GP within 2 years of pre-diagnosis which suggest a good opportunity for early HIV detection in the primary care setting. It is however a challenge to accurately define an ‘optimal’ HIV testing rate for primary care. Here, our positivity rate exceeded 0.2%, suggesting that the current overall rate of HIV testing in our city is likely to be cost-effective. At the time of 2008 DH guidance, a local diagnosed HIV prevalence of 0.2% was considered as a surrogate for an undiagnosed prevalence of ~0.1%. Therefore we suggest that an ‘optimal’ rate of testing in primary care should yield a positivity rate ~0.1%. Based on this assumption, we suggest that testing rates needs to increase further. Our next steps will be to work with GP and public health colleagues and commissioners to better understand: a) how these data may be best fed back to GP practices to influence testing practices; and b) reasons for high inter-practice variations in testing rates. We suggest that other regions may find it helpful to conduct similar analyses.

072
The recording of current non-antiretroviral medication for HIV patients at University Hospitals Birmingham

Abstract - 072

Poster 072

The recording of current non-antiretroviral medication for HIV patients at University Hospitals Birmingham

Ernest Mutengesa1, Meg Boothby2
1University of Birmingham. 2University Hospitals Birmingham

Introduction: Current guidelines state a minimum of 97% of patients on ART* should have a list of all current medication, or note that no medication other than ART is being taken, recorded within the last 15 months.

Aims: Our aim was to evaluate adherence to the target, compared to results of a national audit in 2015. We also assessed where documentation occurred in clinical records, and by which clinicians.

Methods: 101 patients attending in August 2017 were identified for inclusion. Clinic visits from May 2016 to August 2017 were analysed. For all visits (n=511), the documentation of non-ART medication was assessed, and the location in clinic letters or elsewhere was recorded by clinician group. For visits where non-ART medication was not recorded by clinicians (n=78), the proportion where ‘failsafe’ recording by a pharmacist occurred was also determined.

Results: 99% of sampled patients had non-ART medication recorded within the last 15 months. This has improved from 85% in the 2015 audit for the UHB site. In 2017, 13.9% of visits had no evidence of recording non-ART medication, while nurses had the highest percentage of ideal recording (78%). Medication was recorded by pharmacists when clinicians failed to do so in at least 44% of qualifying visits.

Discussion: The improvement from the 2015 audit for the UHB site to 99% exceeds the BHIVA target.

In 2015, recording of non-ART medication at the UHB site was 4.4% lower than the national average.

Following the 2015 audit result, all HIV clinicians, including pharmacists, were asked to routinely record all medications at every patient visit, with the hope of an improvement. The 13% increase reflects the successful change in clinical practice.

We identified that pharmacists were using a separate electronic record and believe if this record was analysed, there would be significantly more than the 44% for proportion of occassions where ‘failsafe’ recording took place.

073
An audit to assess if the 90% target of patients attending outpatient HIV clinics have been screened for smoking history, hypertension, cardiovascular risk, renal function and bone fracture risk as per the BHIVA Standards of Care 2017

Abstract - 073

Poster 073

An audit to assess if the 90% target of patients attending outpatient HIV clinics have been screened for smoking history, hypertension, cardiovascular risk, renal function and bone fracture risk as per the BHIVA Standards of Care 2017

Maithili Varadarajan1, Hiten Thaker2, Sarah Harrison2
1Humber and York HIV Network, Hull. 2Humber and York HIV Network, Hull

Introduction: The UK has an estimated 101,200 PLHIV. With improved management, the survival and quality of life of HIV patients has improved.

An ageing HIV cohort, longer duration of HIV infection and long-term ARV treatment has resulted in a greater prevalence of age related co-morbidities particularly cardiac, renal and bone disease.

Methods: A sample of 50 patients were randomly selected from patients attending HIV outpatient clinics: Castle Hill Hospital (15), Hull Royal Infirmary (15), Grimsby Hospital (10) and Scunthorpe Hospital (10). Data from clinic letters and notes were collected. Statistical analysis including z test of proportions were calculated to compare results to the standards set out in the BHIVA guidelines.

Results: Average age was 47.6 years. 42% of the sample was female and 58% was male.

98% had smoking history documented within the last two years, achieving the 90% target outlined. However, 7 patients (14%) were not given smoking cessation advice. 

100% had their blood pressure recorded every 15 months which meets the 90% target outlined. 

36 patients were aged over 40 years, of which 28 patients (77.78%) had their 10-year CVD risk calculated within 1 year of presentation or within 3 years if they were on ART. This fails to achieve the 90% target outlined. A z test for proportions was calculated (p-value- 0.01)- a statistically significant difference.

According to guidelines >90% of patients should have renal function including the assessment of proteinuria documented every 15 months. 49 patients (98%) had their renal function tested but only 32 patients (64%) were assessed for proteinuria. The p-value associated with the z statistic is <0.0001. Therefore, this difference is highly statistically significant.

7 female patients assumed to be post-menopausal were aged over 50 years of which 4 patients (57.14%) had bone fracture risk assessed within the last three years, failing to achieve the >90% target. The p-value associated with the z statistic is 0.004. This difference is again statistically significant.

Discussion: With increasing life expectancy, it is imperative to screen patients with HIV for cardiovascular, renal and bone disease.

Blood pressure and smoking status was well documented and for most patients, appropriate advice was given.

CVD risk calculation in patients aged over 40 years was documented for only 77.78% of patients. However, some patients had been newly diagnosed with HIV and CVD risk may have been calculated at a later appointment within the time period. To improve, for patients who have not had CVD risk calculated, notifications on the operating system could be employed.

98% of patients underwent routine blood tests to assess renal function. However, only 64% of patients underwent testing for proteinuria. Some patients had been offered a urine dipstick but were unable to provide a sample. In such circumstances, the GP could be prompted to test the urine at a later date for proteinuria or urine PCR.

57.14% of patients aged over 50 years assumed to be post- menopausal had their bone fracture risk assessed within the last three years. However, menopausal status was not well documented and the sample size was small.

In conclusion, to improve adherence to guidelines, a flagging system could be employed to screen HIV patients for CVD. Patients could be offered urine PCR testing to assess for proteinuria. Additionally, to improve screening for bone disease, menopausal status could be added to the discharge letter template where appropriate.

074
HIV care for an ageing cohort in a low-prevalence and largely rural area of England: patient preferences for GP communications and implications for monitoring and managing potential drug-drug interactions (PDDI)

Abstract - 074

Poster 074

HIV care for an ageing cohort in a low-prevalence and largely rural area of England: patient preferences for GP communications and implications for monitoring and manageing potential drug-drug interactions (PDDI)

Christie Mellor1, Jane Fraser2, Ewan Hunter2
1Newcastle University Medical School. 2Newcastle upon Tyne Hospitals NHS Foundation Trust

Introduction: With modern antiretroviral therapy (ART) for HIV the average age of people living with HIV (PLWH) in the UK is increasing. Consequently, there are now greater frequencies of chronic comorbidities along with HIV, and increasingly numerous and complex long term co-prescriptions along with ART, largely originating in primary care. ART is frequently associated with potential drug-drug interactions (PDDIs), largely mediated through induction or inhibition of hepatic enzymes. The British HIV Association recommends that all co-medications are reviewed and documented at every clinical visit to identify PDDIs, and that there is close liaison and regular information exchange between the HIV clinic and the patient’s GP. This may be particularly important in areas with a low prevalence of HIV, where GPs may be less familiar with HIV and its management. Similarly, in such areas there may also be particular factors influencing patients’ willingness to disclose their HIV status to their GP. Where disclosure is whitheld, monitoring and managing PDDIs may be compromised.

Methods: We collected demographic and clinical parameters, current ART combination, co-drugs and details of patient consent for communications between the HIV clinic and their GP, all as documented in the hospital record for all people living with HIV in North Cumbria, whose care is managed by Newcastle-upon-Tyne Hospitals NHS Foundation Trust (NUTH). GP practices of all consenting patients were contacted to retrieve up to date and accurate lists of primary care medications (PCMs). The mechanisms for recording hospital-prescribed medications (HPMs), including ART, at participating practices were surveyed. All co-prescriptions were reviewed for PDDIs using the Liverpool University HIV drug interactions database. To determine HIV clinic and GP information exchange a brief, structured and standardized qualitative questionnaire designed for use in telephone interviews was developed. Clinical and demographic associations with non-disclosure of HIV status to GP were quantified using odds ratios and 95% confidence intervals. Statistical evidence for associations were assessed using the Chi-square or Fisher’s Exact tests for categorical variables, or the Mann-Whitney U test for continuous variables.

Results: Of 100 PLWH who were in active care, 66 (64%) were both registered with a GP and allowed communication between the HIV service and their GP practice (median age 49.6 years (range 22 to 83 years); mean number co-prescriptions 2.7). Ninety-nine individual PDDIs were identified. The most frequently implicated classes of primary care medications (PCMs) were antidepressants (15% of all PDDIs), statins (12%), anti-platelets (11%) and beta-blockers (10%). Mechanisms for viewing and recording hospital-prescribed medications (HPMs) in 22 participating GP practices were variable: in a sizeable minority (22%) there was no automated facility for viewing medications; in nearly half of practices (45%) individual GPs were responsible for directly transcribing any changes to HPMs into primary care records. The overall accuracy of records of PCMs held in the HIV clinic was poor (51.6%). Non-disclosure of HIV status to GPs was more frequent, but without reaching statistical significance, among patients who were aged over 50 years, female and White British vs. other ethnic groups combined. 

Discussion: Accuracy of recording of HPMs and PCMs in primary and secondary care could be improved by greater use of automated systems, and by clear, simple and standardised communications from secondary care highlighting any changes to ART along with information on any PDDIs. The relative frequency if PDDIs between ART and co-medications used as primary or secondary cardiovascular prevention may warrant larger scale prospective assessment to ascertain if this translates into a greater risk of cardiovascular events.

075
The significant of un-usually big Molluscum contagiosum in HIV patients with advanced immunodeficiency in resource limited settings

Abstract - 075

Poster 075

The significant of un-usually big Molluscum contagiosum in HIV patients with advanced immunodeficiency in resource limited settings

Ni Ni Tun1,2, Yee Yee Aung1, Thida Yamin Pyone1, Frank Smithuis1,2
1Medical Action Myanmar, Yangon, Myanmar, 2Myanmar Oxford Clinical Research Unit, Yangon, Myanmar

Introduction: Molluscum contagiosum (MC) is a benign cutaneous viral infection caused by a DNA parvovirus, affecting mainly children and young adults. Though the disease is self-limiting in immune-competent individuals, a severe and prolonged course is associated with Human Immunodeficiency Virus (HIV) infection. The diagnosis can be made by skin scraping or biopsy.

Methods: Medical Action Myanmar (MAM) is a non-profit, medical organization which operates several HIV/TB clinics providing integrated HIV/TB services in Myanmar. In terms of HIV/TB related service, MAM is doing HIV testing and counseling, screening, prevention and treatment of opportunistic infections (OI) in HIV patients, treatment with Antiretroviral therapy (ART), psychosocial counseling, home visit monitoring etcs.

Results: A 12-year-old HIV infected girl presented to MAM clinic on 6th Sep, 2015 with complaint of “pearl white skin lesions” all over the body especially over the face for 9 months. She was diagnosed with HIV at birth. Both parents were HIV positive. The patient started taking ART with the standard first line ART regimen with zidovudine, lamivudine and nevirapine since she was two year of age. On examination, there were multiple, rounded, dome-shaped, pink papules with various size (largest being over 1 cm). The papules were umbilicated and a caseous plug was found. She also had oral candidiasis. Her recent CD4 count was 82 cells/ul. No Viral load was available. No other OIs were detected. The diagnosis of molluscum contagiosum was made by clinical features. Skin biopsy was not available.

The patient was switched to second- line ART containing tenofovir, lamivudine and ritonarvir boosted lopinavir (limited ART availability) with the diagnosis of immunological and clinical failure . After four months on second-line ART, the facial skin lesions became enlarged, red and painful and clinically diagnosed as immune reconstitution inflammatory syndrome (IRIS) and steroid was prescribed. In the meantime, she was consulted with dermatologist for expert opinions. No curettage treatment was given due to risk of bleeding. After five weeks of steroid therapy, the lesions improved with decreased in size and reduced in redness. Steroid was tail-offed. Now, all her skin swelling disappeared and stable on second line ART with her recent CD4 of 350 cells/ul.

Discussion: Molluscum contagiosum is a self- limiting viral skin infection caused by molluscum contagiosum virus (MCV) belonging to the Pox virus family, characterized by the development of flesh-colored, dome-shaped papules on the skin or mucous membranes. It was first described by Bateman in 1817. Lesions are most frequently observed in young children and immunocompromised adults, particularly those with human immunodeficiency virus (HIV).

In patients with HIV infection, lesions spread widely and un-usually big and signify advanced immunosuppression.

The diagnosis of MC depends on whether the lesions are typical or atypical; in typical lesions just the observation of the umbilicated papules is enough; in atypical lesions histopathology, molecular diagnosis by in-situ DNA hybridization, fluorescent antibody test and PCR can be realized to make the diagnosis. Differential diagnosis may be basal cell carcinoma, keratoa-canthoma, cutaneous horn, warts, varicella, intradermal nevi, lichen planus, and opportunistic infections as cryptococcosis or histoplasmosis with cutaneous compromise.

According to the update of a Cochrane Review, no single intervention has been shown to be convincingly effective in the treatment of molluscum contagiosum. As the evidence found did not favour any one treatment, the natural resolution of molluscum contagiosum remains a strong method for dealing with the condition.

In short, MC is un-usually big and rapidly spreading in patients with advanced immunosuppression and in-time detection ART treatment failure and optimizing ART regimen is very important to get effective treatment and patients’ survival especially in resource limited settings.

076
Has the implementation of the multi-disciplinary team to HIV care led to better patient outcomes with regards to viral loads?

Abstract - 076

Poster 076

Has the implementation of the multi-disciplinary team to HIV care led to better patient outcomes with regards to viral loads?

Henry Barrington-White1,2, Hiten Thaker2, Sarah Harrison2, Lorraine Cullen2
1Hull York Medical School. 2Infectious Diseases: Castle Hill Hospital, Hull

Introduction: The MDT approach was introduced to HIV care in the year 2012. This was in part due to successes noted in the approach towards other diseases such as cancer. This involved fields of care including for example psychiatrists, gynaecologists, sexual health and holistic support. After searching through Medline, Embase and consulting the NICE guidelines, it was found that there is little evidence showing the benefit of the HIV MDT approach within the UK health system, therefore this project is aimed to try and find out if the implementation has improved outcomes.

The objectives of the study were to look and see if there were any improvement in the outcomes for HIV patients. It was decided that the best way to do this was to analyse viral loads and see if there was a bigger decrease in viral loads in patients who had undergone the MDT approach. Patient population that was looked at were patients found in the database of Castle Hill Hospital in Hull.

Methods: In order to look at the effectiveness of the MDT, analysis was conducted of 49 randomised patients’ notes after the year 2012 (21 of these patients had undergone an MDT approach, 28 had not) and 39 randomised patients before the year 2012. The viral load at the start of treatment was looked at and the same again after 1 year of treatment for each patient. Other factors also looked at include: drug regimen, race, sexual orientation and age.

Results: Out of the 88 patients, 6 patients were excluded who underwent the MDT process and 8 non-MDT, as 12 of these patients were not officially diagnosed and were given prophylaxis treatment and the final patient became pregnant, therefore her treatment plan changed.

Of the patient population looked at, 69 patients were under the age of 50 (78%) and 19 aged above 50 (22%). 57 patients were male (65%) and 31 were female (35%). 63 patients identified as heterosexual (72%), 9 as homosexual (10%), 3 MSM (3%) and 13 (15%) did not specify.

There seemed to be a greater decrease in viral load in those patients who had undergone the MDT process. This was however not a significant result with a p-value of 0.08. The average viral load results of patients who underwent MDT was a starting viral load of 79,484 and 27 (IU/ml) after 1 year of treatment. The values of non-MDT patients being 468,584 and 632 (IU/ml) respectively.

Discussion: The results showed that MDT led management did not significantly cause a greater decrease in viral load after 1 year compared to non-MDT led management. However there seemed to be a trend suggesting that MDT management led to a greater decrease in viral loads. This study did not measure overall wellbeing of the patients which is discussed at the MDT . It is also important to note that some of the patients who were not part of the MDT had been treated before 2012 and this means they were more likely to be treated with less effective treatments due to advances in HIV care.

077
Renal dysfunction from ART, sorting the horses from the zebras

Abstract - 077

Poster 077

Renal dysfunction from ART, sorting the horses from the zebras

Vino Srirathan, Ewan Hunter
Royal Victoria Infirmary, Newcastle

Introduction: A 65-year-old male with HIV diagnosed over 20 years ago was found to have recent derangement in his renal and bone biochemistry profiles. His adherence to antiretroviral medication was excellent, with sustained viral suppression for many years with CD4 count consistently in the range 700 to 900. His other medical history included pancreatic insufficiency, lumbar osteoarthritis, chronic spinal pain with history of facet joint injections, previous renal colic and recurrent bacteriuria, hypercholesterolaemia, and plantar fasciitis with possible navicular avascular necrosis. His HIV medication for the past 7 years was Tenofovir Disproxil Fumarate (TDF)/Emtricitibine (FTC)/Efavirenz (EFZ) in a fixed-dose once daily combination.

There had been a modest decline in his renal function over the past 5 years, now with an estimated glomerular filtration rate (eGFR) of 51. In addition, the Alkaline Phosphatase (AlkP) was high (646iu/L), serum phosphate low (0.5mmol/L) and urine protein/creatinine ratio (135) was raised. His symptoms were of left loin pain and thigh pain. The biochemical abnormalities in the context of long-term TDF therapy, triggered a tubulopathy screen. His physician also began investigating him for reasons for the new biochemical abnormalities on the suspicion that there may be some features of CKD-Mineral Bone Disease (CKD-MBD).

Methods: Clinical examination revealed bilateral loin discomfort but was otherwise unremarkable, with normal blood pressure and a normal ECG. Renal ultrasound did not reveal any acute focal pathology. The tubulopathy screen found glycosuria on dipstick test, a raised urine retinol binding protein (129mg/L), raised urine phosphate/creatinine ratio (3.5), low serum urate (119umol/L) and low vitamin D (20nmol/L), all confirming tubulopathy.

TDF was switched to Tenofovir Alafenamide (TAF) and Vitamin D replacement was commenced. After these changes, creatinine improved to 126umol/L, eGFR improved to 58 and urine protein/creatinine ratio fell from 142 to 68. The loin and muscle pain improved, but the patient specified now that pain was focussed in the ribs. His AlkP continued to rise, reaching 935iu/L. The remainder of the liver profile was normal. Parathyroid hormone (PTH) was slightly raised at 9.8pmol/L. A renal specialist advised that the AlkP was too high to be explained by CKD-MBD and that an alternative cause needs to be investigated. DEXA and isotope bone scans and a myeloma screen were performed. Bone density was within normal limits for age and sex, serum free light chains were not markedly elevated, but the bone scan revealed multiple bilateral posterior rib fractures in a roughly linear conformation. The patient subsequently gave a corroborative history of a recent episode of trauma while on a bus.

Discussion: TDF is one of the most commonly prescribed antiretrovirals and renal toxicity through tubulopathy has come to be a well-known problem, including the potential to develop Fanconi Syndrome. Tubular dysfunction secondary to TDF therapy may reversed on stopping the drug. The newer preparation of TAF is marketed on its lower renal toxicity compared to TDF and we have shown in this case that TDF-related renal function can significantly improve after switching to TAF. Our patient’s biochemical profile was further complicated by the markedly raised ALP, out of keeping with CKD-MBD and calling into question whether instead a primary bone problem such as malignancy or Paget’s disease were at play (Zebras). However, the additional history of rib fractures (Horse) explained the disproportionately raised AlkP. The clinical lesson is that while it is important to be vigilant for the clinical manifestations of renal disease in HIV-infected patients on treatment, or look for rarer diagnoses, Occam’s Razor may be blunted by Hickam’s Dictum when teasing apart the causes of biochemical abnormalities.

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