Please see letter below from Surinder Singh in response to the article

Richard Ma
Time to improve HIV testing and recording of HIV diagnosis in UK primary care
Sex Transm Infect 2009; 85: 486
http://sti.bmj.com/cgi/content/extract/85/7/486

Richard Ma makes some excellent points in his editorial (1). I would like to ‘correct’ a misperception but add to the current debate about HIV-testing and subsequent care within UK general practice. Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to remember, the serious debate began when patients with HIV and AIDS were denied local services and traditional primary care, particularly when entering the terminal stages of their illness (2). It was also apparent that patients living in one part of the country but receiving care in London were having problems accessing general practitioner (GP)-type services (3). It is true that HAART seemed to focus the mind – it became fairly obvious that prescribing could be one of the facets of care which could be examined in the “shared-care” process. However, in the present context let’s examine some of the dynamics in shared care. Primary care is undoubtedly becoming more involved in the care of patients with HIV/AIDS though it has been argued that general practice could still do more (4), for example in trying to uncover the unidentified 21000 people with HIV infection in the UK (5). Yet up to now the problem has been that patients have liked the highly successful hospital model, a model that has either implicity or in some cases explicity “taken over” GP care. In truth this gold standard model is not sustainable and this is the reason why general practice has to be more involved. The barriers to full primary care involvement have been outlined before (1,3,4) but patient fears about disclosure, confidentiality and stigma are still present. Things change in general practice as they do in Medicine; early in the UK it would necessarily take an hour to ‘counsel’a patient about an HIV test, now we can do the test in the privacy of our consulting room and give the result to the patient 2 minutes later (we are about to embark on point-of-care testing in our practice). The real questions are these: (a) How can we expect a more pressured primary (6) to take up the challenge of increasing testing when the priorities within general practice seem to increase all the time (6). Furthermore it is appropriate to be mindful of the often complex needs of the various heterogenous groups which are affected by HIV infection (gay men, African men, women and children, drug-users)? As the recent research paper states “further work is needed on the mechanisms required to deliver increased HIV testing in primary care”(7). (b) Next and increasingly important especially if more cases of HIV infection are uncovered in GP, what is the optimal location for a systematic approach to HIV/AIDS – the chronic condition? In other words what system or systems will be responsible for regular patient monitoring of CD counts & viral loads, surveillance of cervical smears and perhaps immunisations as well as offering basic prevention activities, for example smoking cessation advice in those already at higher risk of ischaemic heart disease? References:

1. Ma, R. (Editorial) Time to improve HIV testing and recording of HIV diagnosis in UK primary care: Sex Transm Infect 2009;85:486 doi:10.1136/sti.2009.038091

2. Smits,A., Mansfield,S., Singh,S. (1990). Facilitating care of patients with HIV infection by hospital and primary care teams. British Medical Journal 300, 241-243. ISSN: 0959-8146 3. Mansfield,S., Singh,S. (1993). Who should fill the care gap in HIV disease? Lancet 342(8873), 726-728. ISSN: 0140-6736

4. Singh,S., Dunford,A., Carter,Y.H. (2001). Routine care of people with HIV infection and AIDS: should interested general practitioners take the lead? British Journal of General Practice 51(466), 399-403. ISSN: 0960 -1643

5. Health Protection Agency. HIV in the United Kingdom: 2009 Report. 2009, London, Health Protection Agency also available athttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1227515298354 (accessed 7.1.2010)

6. Oakeshott, P; Aghaizu A; Prime, K; Hay P. Promoting long acting reversible contraception & HIV-testing: more work for harassed GPs. BJGP (2009) Vo 59 (569) 895-6 7. Evans HER, Mercer CH,Rait G et al. Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005. Sex Transm Infect 2009;85:520-6.

Conflict of Interest:

None declared