25th September to 23rd October 2009
Angelina Namiba – Project Manager

Summary

• Attended RCGP Introductory Certificate in Sexual Health Training for GPs
• Meetings with Dr Andrew Steeden: re: Steering Group meeting presentation; engaging with GPs & article for PW magazine
• Meeting with Dr Indrajit Ghosh re: Berlin model of care
• Contact with Dr Laura Waters re: presentation at November meeting
• Patient consultations at Body and Soul and The Riverhouse
• Planned consultations at Positively Women; with GPs in early December[what levels of service do they currently provide for PWAs, what concerns/support do they need, what levels of knowledge, support needed, preferred models of care- work with Rebecca];
• Contact with Zoe Sheppard re: consultation with patients at Wharfside clinic
• Submitted staff application forms to Kobler clinic which will enable 1-2-1 with clinic patients – awaiting approval
• Attended Bloomsbury patients network meeting on GPs – asked Peter Twist to join SG
• Editing January edition of PW magazine – Access all areas [access to services with a special focus on access to healthcare ; Dr Steeden and Dr Nelson have agreed to write for the magazine
• Attended UK CAB meeting – focus on HIV and ageing
• Raising awareness of the project – at every opportunity; articles for SOPHIA Forum; Body Positive North West; PW magazine Winter Issue; At a Black History event at the British Library; informally to people at BHIVA etc

Training for GPs
The Royal college of General Practioners –Introductory Certificate in Sexual Health – 25/9/9
I attended the above course run by MedFASH [Medical Foundation for Sexual Health and HIV], at BMA House, as an observer. This was in order to capture information that will inform training recommendations for the model/s of care proposed at the end of the project.
The face –to-face training I attended is the second component of the RCGP’s Introductory Certificate in Sexual Health. The first part is an e-module for distance learning with links into appropriate reading material. The e-module can be accessed on www.doctors.net.uk and is called ‘Sexual Health in General Practice’. The e-module takes approximately 2 hours to complete and participants are required to complete and pass this before they attend the face-to-face training day.
The day lasted approximately 7 hours [including breaks], and is equivalent of six hours of CPD. It contained a short introductory plenary, four interactive group work sessions comprising a didactic presentation followed by discussion time, a where next session on further courses in sexual health offered by BASHH and the FSRH, and time in the end to summarise and reflect on the day’s key learning points.
The four didactic elements each comprised of presentations lasting approximately 25 minutes and fictional case studies based on real experiences were presented to illustrate the kinds of sexual health issues that might present in general practice. Participants were then asked to work in smaller groups to discuss case studies in order to digest and assimilate the information they had just been given. Each group had an experiences tabled facilitator to steer the discussion to ensure that the learning was represented and accurately and the participants were not sidetracked.
Learning outcomes
On completion of the Introductory Certificate on Sexual Health face to face day, course participants will have:

• Discussed examples of evidence based good practice in the management of patients with sexual health issues and related to their own practice
• Discussed relevant clinical guidelines, policies and guidance to healthcare professionals in relation to patients who present with sexual health issues in General Practice
• Identified their individual learning needs in relation the management of patients with sexual health needs in General Practice
• Explored a range of treatment options and discussed strategies for overcoming the barriers to patients with sexual health needs accessing treatment in General Practice
• Practised assessing patients with sexual health needs by means of case studies
• Discussed the roles of other professionals in the management of patients with sexual health issues and the benefits of effective multi-disciplinary working
• Discussed the range of patients who may present with sexual health needs in General Practice with regard to equal opportunities and diversity.

The course was informative, well structured and very practical. I made contact with a couple of GPs who were interested in doing some sessions on HIV awareness for their practice staff etc. [this course is run by Positively Women].
Meeting with Dr Andrew Steeden – 5/10/09
Discussed presentation at the Steering Group meeting of 22/10/09
How best to engage GPs for a focus group. Suggestions included through the PBC Steering Group which Andrew leads on. They have a quarterly training/learning meeting.
We also discussed the possibility of Andrew writing article for the January issue of the Positively Women magazine which will have a focus on access to healthcare.
Meeting with Dr Indrajit Ghosh – 8/10/9
I met with Dr Indrajit Ghosh who currently works at the Mortimer Market but who was previously based in Berlin so he could talk me through how HIV positive patients access primary care in Berlin. [Learning from other models].
The Berlin Model
All GPs working with positive patients are specialised and meet the following criteria
Must have worked in hospital departments of Infectious diseases and gastroentology for at least 1 to 2 years
Must have a background in research work for instance epidemiology
Must have at least 1 ½ to 2 years experience of working in GP surgery seeing HIV positive patients including home care
Most of the surgeries have about 100 plus positive patients and are wholly group practices
Testing is done in GP practices
Patients have private health insurance [unlike the NHS] – 60% of health insurance costs are paid by the patient and 40% through National Insurance / employers?
There are no catchment areas so patients have free choice of GPs
In Berlin only 2 main GUM clinics which cover neurology, ophthalmology and where they also do randomised clinical trials
Patient consultations
Body and Soul Consultation Group – 06/10/09
The Group was facilitated by the project manager plus an HIV positive volunteer from Positively Women and another HIV positive co-facilitator
33 patients [20 women – 4 caucasian/16African, and 13 men – 5 caucasian/8 African]
7 of the patients accessed treatment in St Marys, 1 in Chelsea and Westminster. Out of the 8 patients, 2 live in Westminster and 1 in Chelsea.
Focus Group questions
Did patients have any healthcare needs that were currently not being met?
What were patient’s experiences of using GPs – both good and not so good?
If good, what works? If not so good, how can concerns be addressed.
The final session involved an introduction to different models of care:
The existing model
The Brighton model
GP in the HIV clinic
Polyclinics
And an opportunity for group participants to vote for their preferred model.
Outcomes/recommendations from the group
Addressing concerns raised

• Patients could change GPs
• Education and training for receptionists and other staff – also have one GP who is specialised in treating HIV
• Availability of checklist/system to ensure immediate referral if necessary
• Patients to make themselves aware of and use complaints procedures and speaking up if unhappy about service
• Work needs to be done with policy makers and educational institutions to break mainstream barriers with regards to how society views HIV in general
• Example given of a GP practice that has a specialist HIV doctor that links to clinics that are specialised in various fields. This was felt to be efficient and works very well.

6 people voted for the Existing model
4 people voted for Brighton model
5 people voted for GP in clinic
8 people voted for polyclinics
The River House – Focus Group – 19/10/9
We facilitated a patient consultation focus group at the Riverhouse.
This was attended by 11 patients who live in or access health care in KCW.
4 Caucasian men; 3 Afro Caribbean men; 2 African women 1 Caucasian woman & 1 African man.
A similar format to the Body and Soul Group was followed.
Findings/recommendations:
Similar to recommendations from the Body & Soul Focus group above
3 people voted for Existing model
3 people voted for Brighton model
3 people voted for GP in clinic
2 people voted for Polyclinics
Bloomsbury Patients Network forum discussion on ‘Your GP’ – 15/10/09
The session was chaired by Peter Twist – Forum chair.
The panel of invited speakers included, the commissioner of Primary Care for Camden and Islington, Dr Paul Benn HIV clinician at the Mortimer Market, Dr Bill Beeby a GP from the British Medical Association, Ruth Lowbury – Director of MedFASH and Dr Richard Ma an Islington based GP.
The session started with the various presentations after which patients were given an opportunity share their concerns and experiences of dealing with their GPs, including reasons why, if they didn’t have GPs.
Key points
Dr Paul Benn presented findings from the 2008 survey that was done with patients at the Bloomsbury clinic re: patients’ preference of GP involvement in their care.
He started off by talking about the political drive to move long term manageable conditions to primary care
He also mentioned the BHIVA consultation on models of care [it wasn’t clear whether the consultation has ended.
The survey
3500 patients at the clinic
80% uptake of the questionnaires sent out [520 responded]
Out of 92% registered with GP 77% have disclosed their status. 70% of who are happy for the clinic to write to their GPs.
They were asked a series of questions regarding their healthcare
They were then also asked to choose a model of care they preferred from the 4 below
A – The current model
B – An in house GP who would be accessed by all patients attending the clinic
C – An in-house GP who would be accessed by only Camden and Islington patients
D – Skilling up GPs/Brighton model
60% of the respondents preferred the in-house GP model.
50% of those not registered with GPs preferred the in-house GP model.
Polyclinics/Recommendations
The two GPs then highlighted some of the issues/barriers and recommendations for GPs in treating patients [in their experience]
GPs cannot access patient’s blood test results from their computer – need a special code
One HIV clinician wrote a letter detailing medication that the GP should not prescribe to his positive patient – then forgot to attach the list
GPs with small cohorts will not have much experience in dealing with positive patients – safety in numbers
However – they are very good at managing LTC – it’s their bread and butter.
Recommendations
Need to change attitudes/assumptions that they don’t have HIV positive patients
Need to be a change in attitudes from HIV specialists too in terms of sharing information with about patients with GPs especially where the patient has disclosed and given permission for that information to be shared.
Need good communication between the two professionals
It’s unlikely that all GPs will be able to deliver the quality of care that HIV clinicians do – however it needs to start somewhere.
Where people have experienced discrimination, unnecessary disclosure of information or bad practice [some practices have practice and not just to positive patients– they need to report it.
Some patients had difficulty registering with GPs.
It could be that they fall outside of catchment areas; could be that GPs are away and locums unable to take on new patients; or could be that the particular practice chooses who they register.
There is great will amongst some doctors who do not head up practices
Could be an issue of budget implications
HIV label on patients’ notes – no need as GPs should treat all blood samples as hazards and use the necessary universal precautions.
One of the GPs said the only information he needs form patients in order to maximise their care is their Viral load; CD4 count and what treatment a patient is on.
Other information
Islington operates a similar model to Brighton – [I will follow this up with Islington commissioner]
UKCAB meeting – 23/10/09
On the agenda were:
Caroline Sabin from the UK Collaborative HIV Cohort (UK CHIC) Study who presented a proposed study on HIV and ageing. This presentation was to provide the general ideas that UKCHIC have for the study that it is still in the planning stage. She wanted to see whether the UKCAB can foresee any problems in terms of recruitment (i.e. what would make it an interesting study for patients to participate in), whether the community have suggestions about where UKCHIC could sample 'controls', and whether anyone would be interested in contributing to the study team.
John O’Callaghan-Williamson from the Frontline HIV Forum [a member of the Primary Care Access Project Steering Group], presented a patient-led quantitative and qualitative research study at Chelsea and Westminster. This is a study for HIV+ people over 50, pilot to be delivered by summer 2010. This research is aimed at bringing out patient issues into focus; it is a first major ethical and medically accepted project of its type. It will help plan local health and social care outcomes as well as contribute to global understanding of Ageing with HIV.
Robert James followed with his presentation from the BHIVA community session ‘Will we ever get to be old and wise? This was the positive people’s response to cognitive impairment. It highlighted that cognitive impairment was not been seen in patient groups; it was not yet an issue for Health Trainers in London unlike other mental health problems. Recommendations are that patients should not rush to physiological diagnosis although there is fear that it is the start of HIV related dementia.
Gus Cairns gave an overview of the BHIVA conference and indicated that it wasn’t a study-based conference and his personal standout highlights were:

• Flick Thorley’s workshop on Gay men and the consequences of party drugs; convinced that methamphetamine (crystal meth) has arrived in the London gay community in a big way, is causing harm, and it’s time we wrote about it again.
• Steven Deeks’ talk on elite controllers. Elite controllers are people living with HIV who have HIV levels undetectable by standard viral load tests, without the use of antiretroviral drugs. There are probably fewer than one in a hundred individuals infected with HIV meeting this standard.
• Prof. Gazzard gave a nice clear off-the-cuff talk on why 350 is the best CD4 count at which to start treatment.

Gus felt that the Community Symposium on pathogenesis, that he chaired, went pretty well.
There was also a community Q & A session with ABBOTT pharmaceuticals
The biggest question for Abbott was the price of the new novir (ritonavir). They indicated that the current price would not change in UK and Europe. No new HIV drugs in the pipeline.
Martin Fisher finished off the day with an interactive session on ageing and followed with a final recommendation that treatment for over 50s should begin before CD4 falls below 500.
Recommendation for any proposed care models:
RE: GP training to include information on positive patients aging early - so a need to look out for aging issues earlier.
PW magazine – Access All areas – special focus on access to healthcare
I will guest edit the January issue of the Positively Women magazine which will be on people living with HIV accessing different services. The main focus of the issue will be on access to healthcare and both Drs Andrew Steeden and Mark Nelson have agreed to write from their different perspectives. The editorial team also suggested that it will be useful to include an article on commissioning HIV and primary care services and how funding for these may change in the future and the impact this could have on particularly the HIV population.