Dietitians in HIV Care Newsletter Jan 2019

Welcome to the Dietitians in HIV Care newsletter. We will endeavour to keep you updated with all things related to dietetic care in HIV, but if there is anything else you want included in these newsletters, please get in touch via our website - http://dhiva.org.uk/ or email dhiva@bda.uk.com

Committee positions

At our AGM in October we were excited to announce several vacancies coming up. These are Secretary, Meetings Organisers 1 & 2, Membership Coordinator, Professional Development Officer, and Information, web and resources officer. We are now calling for people to either nominate themselves or another member for these posts.

Please email c.stradling.1@bham.ac.uk before the 1st February 2019 detailing professional history and which post you are standing for. To stand you must be a full member of the HIV Care Group of the BDA.

Should more than one person be nominated for a post then an online election will be held. There are a number of benefits to getting involved with your Specialist Group, including:

Develop valuable job skills – volunteering is a great way to discover something that you are really good at and also develop new skills. Many roles offer the opportunity to gain career enhancing skills, such as leadership, project management, marketing, negotiating and finance management. We also offer formal training for some roles. Make new contacts and friends – volunteering gives you the opportunity to broaden your networks and can expose you to new friends who have common interests. It is also a fantastic opportunity to meet new people who may become future colleagues or mentors.  Many committee members also find it fun! In a speciality such as HIV, building a network of colleagues, who are in close contact is a good way of getting support from other colleagues and creating a network of friends/colleagues. Developing the profession – working as part of the Group committee team, you are leading and ensuring the provision of CPD, representation on national groups and resources for dietitians working in your speciality. This is contributing to the development and advancement of the profession and ultimately driving demand for dietetics.

If you would like further information about these exciting opportunities please contact Clare (Chair)  or Sarah (Secretary) sarah.cassimjee@nhs.net

Conference News

One Dietitians in HIV Care member was able to attend the BHIVA conference in October. Here is some of the interesting  news from the conference –

Over 50’s monitoring audit (Dr Nadia Ekong)- In 2016, 37% of PLWH were over 50 years. 2016- 67.1% of people had an up to date QRISK completed. In 2015- only 50.6% of patients had a QRISK. The national target is for 90% of patients to have an up to date QRISK. Hypertension and hyperlipidaemia are the highest comorbidities. PLWH moving into 50-60 years old are taking 3-4 (sometimes more) non HIV medication (statins, BP medication, antidepressants). 28% of PLWH had a non HIV condition that was a current clinical concern. Overall we are not as good at asking well being questions.

Late diagnosis review process (Dr David Chadwick)- Talker suggested that if a patient dies, and it is felt this is a consequence of late diagnosis a coroner should be informed, and an inquest should be considered. Aiming to improve GP testing and prevent missed opportunities (patients attending GP/A&E with symptoms of HIV but not being tested). It’s estimated (as true number cannot be determined) that there were 150-200 preventable deaths from HIV in 2016.

Women Living with HIV: Are we up to the challenge? (Dr Subathira Dakshina, Dr Sonia Raffe)- BHIVA recommend that all women that have taken the advice to bottle feed should receive free formula- however this is not currently commissioned. U=U is the most stigma reducing message, just need to keep in mind that the PLWH needs to maintain a low VL. Women make up more than 50% of PLWH worldwide, however are often underrepresented in research. 50% women attending HIV services are aged between 45-56 years. Patient report feeling poorly prepared for menopause. It was noted that symptoms are often similar to HIV symptoms. Women with HIV at all ages are at increased risk of fractures. Should all women with HIV at menopausal age be put on HRT? For its bone protecting properties. Should be asking all women when they had their last period.

Chronic obstructive pulmonary disease, interstitial lung disease and cancer (Dr Marc Lipman) - Higher prevalence of lung disease at a younger at in PLWH. Lung cancer is the second biggest cancer killer (after pancreatic cancer). Poor 5 year outcomes. Smoking prevalence high in HIV population. Talker suggested incorporating smoking cessation services in HIV service.

Challenges faced when diagnosing, treating and eliminating TB (Dr Alberto Garcia-Basteiro)- Still using a vaccine from 100 years ago. BCG implemented before clinical trials, therefore first clinical trial on BCG has only just been released. Not currently vaccinating as there is a shortage. HIV coinfection accounts for 20% of all TB deaths.

What is the future of local clinical and community HIV services? (Ms Juliet Reid, Mr George Valiotis, Ms Ceri Dunstan, Mr Rob Coster)- HIV testing not being done in community. 3rd sector cuts resulting in no support for homeless patients. Still a lack of understanding of HIV treatment and transmission which is likely due to stigma. Downward spiral of funding. 12% decrease in funding for community services from 2015/16 to 2016-17. Until we have no new diagnoses of HIV, we still need a HIV specialist service. Need to make services more efficient to ensure utilising the funding as best we can. PLWH and people taking PrEP need to be meaningfully involved in the design and delivery of services and future policies. PLWH access multiple services. The main service gaps that were highlighted are; mental health and peer support (this data was from Scotland, but is likely to be the same in England).

BHIVA Best Practice Management Session: ‘I keep forgetting things’: what to ask, when to worry, what to send and who to refer to (Dr Paul Holmes, Professor Alan Winston) - Dementia: 3 types of memory complaints our patients mention; 1. Memory issues due to HIV. 2. Memory issues due to anxiety or depression. 3. Memory issues due to unrelated diagnosis (Alzheimer’s or dementia). There is evidence to suggest a link between BP and cognitive score. Use of HAART has reduced HIV neurocognitive issues. HIV crosses the blood- brain barrier early in seroconversion. BP is the most important vascular marker for brain. Cholesterol is the most important for heart. Addenbrookes cognitive assessment- 6 staged assessment/examination. http://dementia.ie/images/uploads/site-images/ACE-III_Administration_(UK).pdf. CSF escape- is significant if the VL in the spinal fluid is higher than in plasma. Clinical presentation of high VL in CSF; asymptomatic, neurological symptoms, secondary symptoms (another infection). If a patient has an undetectable VL in plasma, they could still have a detectable VL in CSF. Other countries in Europe test CSF yearly, but discussion at conference about whether this is an unnecessarily invasive thing to do.

Psychological management: practical approaches to intervention and support (Dr Shimu Khamlichi)- No perfect screening tool. Talker suggested the neurocognitive psychological screening tool. Anxiety and stress, as well as age, drugs and alcohol affect the results. Talker suggested reminding our patients about mindfulness and being present in the moment. Also suggested routinely asking our patients about their mental health status.

HIV/hepatitis co-infection and prevention of mother-to-child transmission (Dr Claire Thorne)- 2015/16 data shows only 0.28% of patients were diagnosed with HIV due to vertical transmission.

HIV and disability: a clinical update (Mr Darren Brown, Mr Colin Corbett, Professor Richard Harding, Dr Kelly O’Brien)- Focus groups looked at health challenges faced by PLWH. These were categorised as; symptoms, difficulty with day to day activities, challenges to social inclusion and uncertainty. Participants were asked what disability meant to them- it was defined as episodic disability (disability that varies in severity or length on a day to day/week by week/monthly basis). PLWH report feeling more, experience more depression, and experience greater function impairment despite age. Talker states that functional and physical wellbeing is often forgotten. Ask patient what is meaningful for them? What is important for them? (Being able to go to work, being able to look after their child). Measure disability and screen to help understand health related challenges. This will help shape care into patient centred care. There is a need for outcomes and valid research in rehabilitation. HIV disability questionnaire (69 items)- ask patient to complete thinking about ‘good and bad days’, this will help capture episodic disability. From this questionnaire, uncertainty was scores as highest presence and severity across all ages. Uncertainty is a key component of disability. Also uncertainty from AHP’s- treating an aging HIV population. There was no literature in the western world on prevalence of disability in PLWH. Darren Brown has researched within his area of London- Are PLWH reporting more disability than the general population, and compared to studies from Africa. Difficult to compare the results from London to studies from areas of Africa- there is likely to be a significant cultural difference in how we perceive and report disability. Need to be able to access data on how people accessing generic non HIV services perceive disability. His findings showed that a 3rd of people accessing groups also access 1:1 support.

Dispelling the myths around HIV and ageing and changing the causes of mortality (Professor Caroline Sabin)- Aging population comes with an increased prevalence of comorbidities. PLWH have more comorbidities than non HIV people. HIV causes premature aging. However: there is an increased rate of STI’s, viral coinfections, smoking and recreational drug use- could it be that these are causing the premature aging rather than the HIV. Comorbidities are multifactorial and HIV is just 1 factor. Cancer is becoming a more prominent cause of death in HIV. Studies aren’t really showing accelerated aging in PLWH. PLWH have biomarkers that suggest their bodies are older than their true age- but so did non HIV people. Poppy study- looking at HIV and aging.

The gut microbiome (Dr Caroline Le Roy)- Start to see a change in gut microbiome in aging. Eating and medication shapes gut microbiome. 70% of medications impact gut microbiome. HIV patients have a unique type of gut microbiota. Distinct signature in gut of PLWH- ?if consequence of infection or the treatment. Diverse diet and pro/pre biotics could help with gut microbiome- not enough evidence.

 

Let us take this opportunity to wish all our members a very happy New Year.

From the Dietitians in HIV Care Committee