News & Media > Coronavirus (COVID-19) and HIV - BHIVA Statements >

COVID-19 & shielding: advice for HIV clinicians, GPs and people living with HIV

Thursday 23 April 2020

This guidance addresses two key issues related to COVID-19 and shielding:
A. People considered to be at highest clinical risk who are not on the official CMO list.
B. People who have incorrectly received Government advice to shield.

Much of this guidance is applicable to all home nations, some outlined processes are specific to England. The Royal College of General Practitioners (RCGP) has a useful summary of shielding actions and advice for each nation, which can be accessed on their website [1].

Key recommendations:
1. HIV services should ensure people likely to be at highest clinical risk of severe COVID-19 are contacted, advised to shield and flagged to the appropriate health body, including:
a. People with a CD4 count less than 50 cells/microL
b. People with an opportunistic illness in the last 6 months
c. People with significant multi-morbidity*

2. HIV services should review how they manage patients at the highest clinical risk in order to safely minimise the risk of exposure to COVID-19.
3. HIV services should ensure people who have received any shielding advice in error have access to the correct information as provided by BHIVA and THT.

Where any HIV service does not have the capability or capacity to identify high-risk individuals, the HARS team at PHE can provide this information. Please contact HARSQueries@phe.gov.uk.

A. People considered to be at highest clinical risk who are not on the official CMO list

How clinicians can add people they consider to be at highest clinical risk to the shielding list (England).
People living with a condition on the CMO list of those at highest clinical risk are advised to shield; this does not include HIV and there are no plans to amend this list [2].

However, updated guidance from 12th April 2020 includes a mechanism to add people to the list thus granting them access to the associated support. Supporting documents, including patient and clinician FAQs, can be accessed in full online [3].

BHIVA & THT have suggested that people with HIV and one or more of the following conditions should be categorised at highest clinical risk and consideration made of adding them to the list for shielding:
a. People with a CD4 count less than 50 cells/microL
b. People with an opportunistic illness in the last 6 months
c. People with significant multi-morbidity*

Ultimately it is a clinical decision as to whether someone is high risk and the criteria suggested are advisory; decisions should be made on an individual basis in discussion with the patient, including the practicalities of shielding and patient wishes.

On the 10th April all Trusts were contacted by NHSEI inviting them to add additional patients to the list of those at highest clinical risk. These additional patients include those in one of the categories of the CMO list along with individuals considered by their clinician to be at highest clinical risk [4] - please note the deadline of 13th April for submissions has been extended indefinitely.

Essentially each Trust will have someone allocated to submit data to the Strategic Data Collection Service (SCDS) https://datacollection.sdcs.digital.nhs.uk/ - data can be submitted once daily and if you do not know who your Trust rep is you can contact emergency.collections@nhs.net to find out.

If you identify someone as high risk you should:
1. Speak to the patient to ensure they understand the implications of shielding.
2. Having explained the process, including data management and transparency (see below), seek their verbal consent to submit their details.
3. Add the patient to the central list via your Trusts SCDS route.
4. Send the patient a shielding letter [5].
5. Encourage them to register as extremely vulnerable even if they do not require daily living support at this time. This can be done through the link embedded in the above letter https://www.gov.uk/coronavirus-extremely-vulnerable
6. Inform their GP where you have permission to do so.

B. People who have incorrectly received Government advice to shield

How to manage patients flagged as high risk in error (England)
Identification of people at highest clinical risk was undertaken by NHS England from hospital records and then from primary care records (from April 7th). It was during the second phase that people with HIV may have received a text incorrectly categorising them as being at highest clinical risk and advising them to shield. This was due to variability in the way HIV related conditions (including immunosuppression) are coded. BHIVA and THT have previously issued a statement (April 8th) reassuring people living with HIV that they, in general, are not at highest clinical risk and NHSE will be reinforcing this with a communication over the next few days.

GPs can add a ‘low’ or ‘moderate’ risk flag to patient records, which will override any high-risk flags added to GP records by NHS Digital. There are no plans currently to contact patients flagged as high-risk again so it is not a priority to contact GPs to alter flags at present. ‘Moderate’ risk would include those people who may be at higher risk as described in the BHIVA/THT statement i.e. CD4 less than 200 or detectable viral load.

Data Management and Transparency
Full details on how this data is collected, how it is processed, and what NHS Digital do with the data can be seen on the NHS Digital website [6].

NHS Digital is the controller of the personal data in the List under the General Data Protection Regulation 2016 (GDPR) jointly with the Secretary of State for Health and Social Care, who has directed NHS Digital to collect and analyse data for purposes relating to COVID-19 under the COVID-19 Public Health Directions 2020 (COVID-19 Directions).

Identifying patients for inclusion in the initial List was carried out by NHS Digital using data they already hold as the national safe haven for health and care data in England. They also collected additional data from GP practices in England and NHS Blood and Transplant about those patients who were determined to be clinically extremely vulnerable. They are sharing relevant information from the Shielded Patient List with organisations who have responsibilities for providing care and support to the patients on the List. This includes:

  • GP practices about their own patients on the List

  • NHS hospitals about their own patients on the List

  • Other NHS organisations, Government departments and local authorities

  • The Cabinet Office, who are responsible for providing the Extremely Vulnerable Persons Service. More information about how the Cabinet Office uses personal data for that Service, who it shares information with and how long it will keep the information is explained in its Privacy Policy.

  • NHS clinical commissioning groups (CCGs), for the purposes of providing GP practices with support, and patients in their CCG area with support and care

  • Capita, for the purposes of distributing letters to shielded patients

  • NHS Business Services Authority, for the purposes of sending text messages to shielded patients.

Personal information, except for confidential health and care information, may also be shared with trusted supermarkets and other suppliers, so they can prioritise extremely vulnerable person orders if it is indicated that they need help getting basic supplies.

*NHS guidance for GPs suggests that people considered at high risk, for example due to ‘severe multimorbidity’, can also be added to the central list; specific guidance from the RCGP is pending; there may be patients with HIV for whom this is relevant.

Weblinks

1. National shielding advice from RCGP: https://www.rcgp.org.uk/covid-19/latest-covid-19-guidance-in-your-area.aspx
2. CMO list of people at highest clinical risk: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#what-do-we-mean-by-extremely-vulnerable
3. Managing people at highest clinical risk: https://www.england.nhs.uk/coronavirus/publication/trusts-at-risk-patients/
4. Adding people at highest clinical risk: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0276-Highest-risk-patients-instruction-letter-for-Trusts.pdf
5. Shielding letter: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/at-risk-patient-letter-march-2020.pdf
6. NHS data use: https://digital.nhs.uk/coronavirus/shielded-patient-list/shielded-patient-list-transparency-notice


For further information, please contact bhiva@bhiva.org or for media enquiries, please contact Jo Josh at jo@commsbiz.com or +44 (0)7787 530922.