Thursday 8 October 2020
In light of the rising number of COVID cases, and NHS organisations reinitiating contingency plans for managing the epidemic, we are updating our guidance for HIV services.
We outline core service elements that should be maintained whilst recognising that all NHS staff have a role to play in dealing with the unprecedented pandemic and national emergency that is COVID-19. Ensuring patients understand that services will be limited, non-urgent care restricted, and that changes may be implemented at short notice, but that all services will ensure a safe standard of care, is crucial.
1. We do not advise extending the interval between routine monitoring for more than 12 months.
2. Services should do all they can, within their capacity, to support people to attend for investigations, reassuring them about infection control measures, offering potential alternatives (eg liaising with primary care to arrange monitoring where their GP is able to, utilising existing community services or liaising with other secondary care services where appropriate) and explaining and discussing the risks of no monitoring.
3. Where it is not possible to undertake usual monitoring, ART should still be prescribed in all but exceptional cases. Patients should be counselled that, in the absence of monitoring, there is a risk (albeit low) of unrecognised toxicity and/or unrecognised virological failure (which could result in morbidity, resistance development and onward transmission). Ultimately, for the vast majority of patients, the risk of interrupting therapy is considered far greater than the risk of prescribing without monitoring, and the risk of virologic failure is reduced with longer duration of viral suppression on ART. This discussion, and the patient’s consent to continue ART despite these potential risks, should be documented clearly in the notes.
4. In terms of service pressures, we reiterate our previous advice that the following core service elements must be maintained, and advise that where any individual service may not have the capacity to do so, they work within their networks to develop appropriate pathways:
a. Blood monitoring that ensures urgent tests (eg new symptoms, risk of virological failure, advanced HIV) can be offered, and preserves capacity to ensure all patients can access monitoring at least annually.
b. Ability to assess new diagnoses and start ART in line with existing guidance.
c. Capacity to undertake medication switch where more than minimal toxicity or tolerability issues arise necessitating monitoring.
d. Antenatal assessment and advice.
e. HIV-TB, HIV malignancy and other specialist services where any delay in assessment would cause significant harm.
f. Assessment of mental health, alcohol/drug issues and domestic abuse with clear pathways for appropriate referral and/or signposting where issues are identified.
5. Clinics should ensure they have up to date information available about local and national HIV support organisations and maintain referrals into those services, including for patients with new support needs during COVID.
6. We suggest that services should have mechanisms in place to review patients who are vulnerable, who are at higher risk of COVID-19 complications (eg due to other co-morbidities) or negative HIV outcomes (eg detectable viraemia, low CD4). If feasible, the use of self-isolating staff to offer ‘check in & chat’ services may be helpful.
7. We advise all services ensure the information that they provide to their service users is accessible and up to date.
8. We recommend all services ensure their patients, and primary care providers, are aware of the guidance to offer pneumococcal and annual influenza vaccinations.
9. BHIVA is planning a registry of suspected/confirmed COVID-19 cases amongst people with HIV so we encourage all services to document:
a. Confirmed COVID-19 cases;
b. Suspected COVID-19 cases;
c. Positive COVID tests;
d. Examples of harm related to COVID-19 or service changes secondary to COVID-19;
e. As much details related to testing, symptoms, level of care and outcomes as is feasible.
For further information, please contact Jo Josh on +44 (0)7787 530922 or firstname.lastname@example.org.