UK-CAB 22 – Meeting Report

HIV testing and monitoring

13 July 2007

Contents

1. HIV rapid testing
2. Conference feedback
3. Monitoring tests in HIV infection
4. Viral tropism and methodological issues
5. Monitoring HIV infection and treatment in the 2nd decade of HAART
6. Update on PI monotherapy study
7. UK-CAB business
8. PICUM conference on access to healthcare for undocumented migrants
9. AOB

HIV rapid testing

Adam Wilkinson, THT

THT involvement started in 2003 thanks to a partnership with the Chelsea and Westminster Hospital. Later on a clinic opened in Peckham, linked with the Guy’s and St Thomas’ Trust. The objective is to improve sexual health and HIV testing.

Rapid testing service was established. With the financial help of GSK, a pilot scheme across the UK was extended.

Q: Why Rapid HIV testing?
A: A steady increase in new diagnosis. Reduced death rates by testing early.

Q: Are the kits reliable?
A: The services are out of traditional clinical settings. The price of the kits is £10 each in the UK vs. the cost of traditional testing in GU setting, which is more expensive.
Changing times: HIV is a long term condition, changes in immigration law, prosecutions which add to stigma, more women and children infected, and co-infection.

The mission of THT is to reduce the spread of HIV and promote good health, campaign for better public understanding.

Introduction of new technologies and the test kits:

Abbott HIV test kit detects HIV1 and 2.

Demonstration of the mechanics of the kit.
Additional protocols like using gloves and goggles.
The kit can pick up other viral materials, not just HIV.

Q: Why Abbott?
A: It was the choice of the consultants. Other kits can be used. Now it’s about what’s cheap and available.

Another kit using a small well system, with 3 bottles is available. The added advantage of using this kit is that you can get the result in 3 minutes and it is also very cheap.

There has been interesting debates about where to place clinics: Mobile units (e.g. in Coventry), gyms, THT buildings, etc.

These clinics are nurse led clinics.

Q: On Pre-test counselling. Who leads the discussion?
A: Initially a health adviser.

Q: You don’t have input from the voluntary sector?
A: The THT employs nurses.

Comment: Pre-test counselling doesn’t exist anymore. There is very little evidence that it was of value.

Q: How hard is it to reach people?
A: There is a need to develop outreach programmes, like in bars for example, information material is needed.

Q: Does the outreach in club venues work?
A: Not in particular, depends on the campaign.

Q: How many venues are there in London? Is it free?
A: 7 in London. Yes.

Q: How do you reach groups like Africans? African organisations all have the leaflets. For Africans, it is felt it works better if their own people are involved.
A: There is a service in Peckham targeted at African communities.

Q: Is counselling provided for people with a negative result?
A: Yes, there is a Post-test discussion.

Q: What is the uptake of weekend facilities?
A: Weekend stuff is targeted at young people.

Q: Have changes in immigration law had an impact?
A: You have to encourage people. Better to know your diagnosis.

Q: Are issues on patient’s confidentiality addressed?
A: People can have a level of anonymity which is the same as in the GU setting. They do not have to give a name.

Q: Do you target young people?
A: We are offering HIV test to young people.

Q: Is community STI testing available? Does anything exist for adults?
A: In Leeds, syphilis, chlamydia and Hep B are available.

Comment: Reference to a study in Scotland: the regular place people go to is GUM clinics.
A. The clinics we offer are for asymptomatic only.

Q: Is rapid testing not usually linked with false positive and negative results?
A: Evidence shows 1 in 1000 false negative results. The kits are date marked and are reliable. A dummy is used each time the clinic opens.

Comment: A point is made on African led churches getting ready to start fast testing in churches without knowing the rules in this country. The results are announced in the church (like in Nigeria).

Q: Is there a legal requirement to employ nurses?
A: Yes, there is.

Q: On success criteria: Could we get a better positivity result average than GU clinics?
A. Yes.

Q: Would these churches (see above) be acting illegally? How can this challenge be addressed?
A: Churches feel quite defensive, they are not listening. They are determined to go ahead. Churches are ignorant on HIV issues.

Comment: I run a clinic at the Lighthouse. Two men came for testing. The church encourages testing. If people are found to be HIV+, the Church tells them that prayer works. This is a worrying message.

Comment: It is often impossible to get the name of the churches. One of them is the Leeds Apostolic Faith Mission.

Conference feedback

Gus Cairns, Brian West

Gus Cairns makes a point of clarification on the BHIVA community seminars: EPR (Electronic Patient Records/Connecting for Health) is the chosen topic.

Brian West comments on Abbott’s latest actions and the letter sent by EATG (ECAB). Can the UK-CAB send a letter of complaint to Abbott?

Gus makes a point of clarification on the BHIVA clinical paper on mortality.

Gus Cairns makes a point of clarification on the AIDS Impact Conference. Topics included: reasons people go on having unsafe sex, HIV and employment, benefit of switching treatments, quality of life, undiagnosed malignancies.

Monitoring tests in HIV infection

Matthew Williams

Q: Why do resistance testing on diagnosis?
A: To pick up mutations at initial infection, which will fade to below detectable levels over time as the detectable virus becomes wild type. These mutations will not be picked up later. Knowing about those mutations is important, as this will inform the choice of the combination.

Q: How about some tests on urine compared to tests being done on blood, what is the added value of a urine sample?
A: None. Except for babies or young children where using needles is more difficult.

Q: What is the most liver damaging over-the-counter (OTC) medicine?
A: Paracetamol.

Q: Different clinics use different assays and different cut-offs as a result for viral load testing: under 40, under 20 or under 50 copies/mL. So what does it mean to suddenly be told that you are under 40 but detectable vs. undetectable, under 50?

Comment: It is important that the community understands what it means. The important thing is that it is under 50 copies/mL.

Comment. Cancer markers are used more frequently recently as people live longer.

Presentation on viral tropism and methodological issues

Matthew Williams and Svilen Konov

Viral tropism is important for a new class of drugs called CCR5 inhibitors. These are a kind of entry inhibitor and stop HIV binding to cells by blocking the CCR5 co-receptor.

Tropic = shape response (from Middle English, tropic. Old French, tropique. Latin, tropicus. Greek, tropikos, turn)

Viral Tropism = the way the virus responds to external stimulus in order to attach to and infect cells.

The slides from the presentation

Scientists studying HIV discovered by the 1990s that different forms of HIV use different coreceptors to attach to cells.

The most commonly transmitted strains of HIV use the CCR5 co-receptor. Strains that develop in late stage infection often use CXCR4 receptors.

The terms sensitivity and specificity were explained by Svilen. They are used to analyse the value of screening or tests. Any screening test for a condition and for each patient, we may have:

  • The condition itself may be present or absent
  • The test result may be positive or negative
Test results Condition
Present Absent
Positive A B (false positive)
Negative C (false negative) D

Sensitivity: If a patient has the condition, we need to know how oftent the test will be positive, i.e. “positive in condition”. This is calculated from: A/A+C or in other words it shows the rate of pick-up of the condition in a test, or expressed differently the proportion of people with a condition who are correctly diagnosed by the test.

Specificity: If the patient is in fact healthy, we want to know how often the test will be negative. This is given by: D/D+B, in other words, the proportion of individuals without the condition who are correctly identified as negative by the diagnostic test.

Monitoring HIV infection and treatment in the 2nd decade of HAART

Dr Simon Edwards, Mortimer Market Centre, UCH

Which tests do we still need to do and which do we want to introduce? How often? In whom? Do we have any guidelines? With a steady increase in the number of patients and an increase in infections such as syphilis, LGV, HCV, etc, we need to look at the utility of tests. Do we do too many unnecessary tests? Are we spending money on wrong tests? Is individualised testing the way forward? Is there a risk that we may miss important tests? A presentation on the new system for monitoring that Mortimer Market Centre intends to implement.

Q: What is your threshold CD4 count for an annual test?
A: Not clear.

Q: Are you going to present your model to the BHIVA Conference? Is it just a pilot scheme?
A: We are looking at assessing the validity of this approach.

Q: On Best practise. How do we monitor what’s happening and what’s happened when moving from one system to another?
A: Patient audits.

Update on PI monotherapy study

Nick Paton Clinical Trials Unit, MRC

Q: Comment on gender distribution.
A: Centres all over the country have been approached + Dublin.

Q: How long do people have to be on therapy before they can join?
A: Six months with an undetectable viral load.

Q: Do you have an idea of the time frame?
A: Answer from HTA by August/September. The protocol will be finalised one or two months after that.

The recruitment at centres is likely to start in November.

UK-CAB business

The Chair asks if anyone has any ideas for future topics for UK-CAB meetings.

A call will be made online.

PICUM (Platform for International Cooperation on Undocumented Migrants) conference on access to healthcare for undocumented migrants

Christophe Palaggi.

Background: What is PICUM? How did EATG get involved with PICUM? This in line with its Mission Statement. EATG is not a migrant organisation but is monitoring the implementation of the rights of migrants to healthcare services as a part of its activities.

This has been done in the past by the identification of collaborating partners, especially in close cooperation with the European Aids and Mobility network.

The EATG Policy Working Group recommended including issues related to the right of migrants to treatment, care and prevention during the CSF (Civil Society Forum) meetings in its agenda. This has been done in close partnership with A&M and the other networks present in the CSF.

The European Aids Treatment Group organised a European conference in Lisbon on the right to HIV and AIDS prevention, treatment, care and support for migrants and ethnic minorities in Europe.

Members of the Policy Working Group came up with a project proposal to support the European Correlation conference on “Social Inclusion and Health”, Sofia 27-29th September 2007. The aim of this collaboration is to secure the follow-up of the recommendations from the Lisbon conference by active participation.

Key point: A new Directive will be voted after the summer by the European Parliament on Access to Health care in the European Union. The last one was votes in 2005 and included no mention of the health condition of deported people.

British MEP Jean Lambert is the Chair of the committee on Access to healthcare for undocumented Migrants and she closed the conference.

She highlighted the link with current debates about the future of Health care in the Union (Market vs. Social approach). Healthcare is a universal and indivisible right.

The presence of British organisations at this conference was overwhelming and was illustrated by many interventions from the audience highlighting the predicament of “undocumented” migrants or “failed “asylum seekers in the UK who no longer qualify for free NHS care since 2004. This was confirmed by a rep. of Medecins du Monde. One of the presentations was from a rep. from the GLA (Greater London Authority).

No British HIV&AIDS NGO’s appeared to be present at this conference although HIV&AIDS was mentioned on many occasions during the course of the conference.

AOB

Next meeting 2 November 2007

Attendees

Salima Adatla, Royal Free Hospital, London
Elijah Amooti, African Eye Trust, London
Kenneth Anochie, London
Gus Cairns, London
Jabulani Chwaula, THT, London
Paul Clift, London
Ben Cromarty, North Yorkshire AIDS Action
Richard Jackson, THT, Bristol
Rupert Jones, West Yorkshire African Group, Leeds
Stephen Kataya, The Rain Trust, London
Sunil Kumar Kedala, Compassion Foundation Hospital, India
Mary Makarau, St Charles Hospital, London
Edwin Mapara, CHAT, London
Weathered Marangoh, Redhill
Michael Marr, Waverley Care Solas, Edinburgh
Clement Musonda, The Rain Trust, London
Smart Nndozie Onukaogu, Enfield
Christophe Palaggi, EATG, London
Elias Phiri, AAEGRO, London
Jo Robinson, THT, London
Brian West, HIV Scotland, Edinburgh

Apologies:
Robert James, UK CAB Steering Group
Simon Collins, HIV i-Base

Speakers

Adam Wilkinson, THT, London
Matthew Williams, UK-CAB, Brighton
Dr Simon Edwards, Mortimer Market Centre, London
Svilen Konov, HIV i-Base, London

Views expressed in this report are personal and do not represent the views of any organisation involved in the meeting. Reasonable steps have been taken to ensure this report is accurate but it is for information only and not a substitue for professional advice.

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Published: July 13, 2007
Last edited: December 19, 2010