Friday 17 December 2021
In light of another phase of rising COVID cases, and NHS organisations reinitiating contingency plans for managing the epidemic, we are reiterating our guidance for HIV services.
HIV services, including outpatient care, are an essential service. Local teams will need to ensure they have sufficient staffing to provide uninterrupted, safe care and use this as a basis for negotiations related to redeployment or service changes. Where feasible, individual clinics should liaise with other services in their local networks to, where appropriate, deliver some service elements at network level.
We outline core service elements that should be maintained whilst recognising that all NHS staff have a role to play in dealing with the COVID-19 national emergency. It is crucial to ensuire that patients understand that access to services may well 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.
1. We do not advise extending the interval between routine monitoring for more than 12 months.
2. We advise services shift to non-face-to-face consultations where possible but continue to provide sufficient face-to-face capacity, following local organisation infection control requirements, for essential attendance. Please see BHIVA guidance on virtual consultations: https://www.bhiva.org/guidance-for-virtual-consultations-for-people-with-HIV
3. 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, utilising existing community services or liaising with other secondary care services, where appropriate) and explaining and discussing the risks of not monitoring.
4. 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.
5. 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 preserving 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, virological rebound or treatment-limiting drug-drug interactions 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. We suggest treatment for latent TB can be deferred until services are able to reliably monitor therapy.
f. Assessment of mental health, alcohol/drug issues and domestic abuse with clear pathways for appropriate referral and/or signposting where issues are identified.
6. HIV support organisations: 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.
7. Vulnerable patients: we recommend 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.
8. Up to date information for service users: we advise all services ensure the information that they provide to their service users is accessible and up to date.
9. Pneumococcal and influenza vaccinations: we recommend all services ensure their patients, and primary care providers, are aware of the guidance to offer pneumococcal and annual influenza vaccinations.
10. Documentation: to facilitate future service planning 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 detail related to testing, symptoms, level of care and outcomes as is feasible.