Patient HIV care and management are provided through a multidisciplinary approach. Initial diagnosis and treatment initiation may occur at the initial appointment provided it is clinically appropriate. Patients should be provided the opportunity of arrangements for GP shared care to address primary care needs. See HIV shared care for GPs.
The ASHM HIV Management Guidelines outline the care and management to be offered to patients during assessment and initial management. Services or individual clinicians may choose to vary monitoring depending on the clinical presentation of the individual patient.
Ongoing management of a patient on HIV treatment includes an annual review of co-morbidities such as cardiovascular, renal and bone disease in consultation with the patient’s primary care or shared care provider. This review in well HIV patients may be undertaken through a nurse-led model of annual co-morbidity screening. This care should be performed in line with recommended clinical guidelines below. It should be performed under a defined scope of practice and under the supervision of an HIV specialist.
PFSHSs have procedures in place to maximise the number of patients who remain engaged in care via a system of scheduling and/or recall.
HIV assessment and initial management (baseline)
Clinical assessment as outlined by the ASHM HIV Management Guidelines (history and examination) includes the following:
a focus on identiﬁcation of clinical indicators of the stage of HIV disease and associated infections STI and BBV infection assessment including vaccination history assessment of the social context of the infection, including drug and alcohol risk factors assessment of the psychological impact of the diagnosis laboratory evaluation, including the stage of HIV infection and baseline serological testing assessment of co-morbidities and co-infections (this may include undertaking investigations) health maintenance, including prevention of co-morbidities, STIs and need for ongoing vaccination education and support including medication adherence risk assessment and prevention public health measures.
Recommended laboratory testing when monitoring patients before and after initiation of antiviral treatment is outlined at: https://aidsinfo.nih.gov/guidelines/htmltables/1/5570
The ASHM Antiretroviral Guidelines may provide additional information.
Adherence to ARTThe Supporting Adherence tool outlines steps to be undertaken to support patients’ adherence to ART.
The following resources outline the recommended monitoring of HIV patients on antiretroviral treatment:https://aidsinfo.nih.gov/guidelines/htmltables/1/5570
Co-morbidity preventionPrevention and management of co-morbidities are well defined in Part III of the European AIDS Clinical Society Guidelines.
Education is an important tool in assisting patients to understand the importance of routine monitoring while on HIV treatment, to adhere to treatment, to make lifestyle changes to prevent non-HIV co-morbidities, and to understand available prevention methods for sexual partners.A variety of resources is available from groups and community organisations. A list of community HIV organisations and their websites can be found here.
- use of a condom or
- having an HIV viral load of less than 200 copies/mL (usually resulting from being on effective treatment) or
- seeking and receiving confirmation from a sexual partner that they are taking HIV pre-exposure prophylaxis (PrEP).
Pre-exposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP) are effective in preventing HIV transmission. Patients with HIV should be made aware of both PrEP and nPEP and where to access them as well as the role of condoms in preventing HIV transmission.
Patients should also be supplied with a schedule of follow-up appointments and supported through a recall system to ensure that monitoring is performed in a timely manner. Follow-up is required when:
- a patient has failed to attend their appointment after initial diagnosis where treatment was not yet initiated
- there is a concern the patient is no longer on treatment.
The minimum follow-up is at least four attempts over two weeks, using two different notification methods (if available) and including attempts outside normal business hours. Where the patient cannot be located or does not respond to contact efforts, seek advice from a senior clinician and consider whether a case conference is necessary. If no response is received but an address is available, consider sending a registered letter. Document all attempts at contact.
If the patient attends a follow-up appointment after initial diagnosis, revisit partner notification. This should be an ongoing conversation with the patient while there is detectable viral load.Provider referral is the preferred method to notify partners of a possible HIV exposure risk.
Services must have in place a mechanism for case conferences where complex cases can be discussed using a multidisciplinary team approach. For services with no multidisciplinary team on site this could be undertaken remotely through teleconference or videoconference with the organisation providing HIV clinical services to the patient.Examples of presentations or situations that would benefit from conferencing are patients:
with complex psychosocial needs with co-morbidities with immune deficiency or lack of viral control with adherence difficulties with hospital admissions with issues around access to treatment or care who have not returned for follow-up care and management despite required attempts by the service to contact them for whom there are concerns that they may be placing others at risk for whom complex partner notification needs have been identified
Maintain complete consultation documentation as outlined in the local medical record plus:
References and further reading
- Hoy J, Lewin S, Post JJ, Street A, editors. HIV management in Australasia: a guide for clinical care. Sydney: Australasian Society for HIV Medicine (ASHM); 2009. http://hivmanagement.ashm.org.au/
- Bradford D, Hoy J, Matthews G, editors. HIV, viral hepatitis and STIs: a guide for primary care. Sydney: Australasian Society for HIV Medicine (ASHM); 2008. https://www.ashm.org.au/products/product/1976963411
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) Sub-Committee for Guidance on HIV Management in Australia. Antiretroviral guidelines. Australian commentary on the US Department of Health and Human Services (DHHS) guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Sydney: ASHM; 2014. Available at: http://arv.ashm.org.au/
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). National HIV testing policy. Sydney: ASHM; 2017. Available at: http://testingportal.ashm.org.au/images/HIV_Testing_Policy_Feb_2017.pdf
- NSW Health. Infection prevention and control policy. Sydney: NSW Health; 2017. Available at: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_013.pdf
- Foster R, Morris S, Ryder N, Wray L, McNulty A. Screening of HIV-infected patients for non-AIDS-related morbidity: an evidence-based model of practice. Sexual Health. 2011;8(1):30–42. Abstract available at: http://www.publish.csiro.au/nid/164/paper/SH10021.htm