Policy responses and statements
- Name of organisation:
- NHS Quality Improvement
Scotland (NHS QIS)
- Name of policy document:
- Draft Clinical standards for HIV services
- Deadline for response:
- 17 December 2010
Background: Building on their previous
work on long term conditions, and in response to matters raised by
professionals involved in HIV service provision, patient groups and
the Scottish Government, NHS Quality Improvement Scotland took the
decision to develop clinical standards for HIV services. These standards
aim to improve the quality and co-ordination of HIV care (prevention,
recognition and diagnosis, and treatment and care) for HIV infected
individuals and for those at high risk of acquiring infection.
COMMENTS ON
NHS
QUALITY IMPROVEMENT SCOTLAND
DRAFT CLINICAL STANDARDS
FOR HIV SERVICES
The Royal College of Physicians of Edinburgh is pleased to respond
to NHS Quality Improvement Scotland on its consultation on the Draft
Clinical standards for HIV services.
The pace of change of social attitudes and behaviours, options for
treatment and overall management of people with HIV continues at an
impressive pace. Over a short period, the prospects for people
with HIV have been transformed. Near-normal survival expectations
can now be envisaged for those who carry this virus, a vision which
is in stark contrast to the dire prognosis associated with a disease
that first emerged 30 years ago. Then, it was considered
to be inexorable and incurable. Only 20 years ago, the HIV
epidemic was regarded as almost uncontrollable.
With this background, NHS Scotland needs to ensure that services for
people with HIV are optimal to offer highly skilled care in a combined
and integrated way, coping with rapid development, rising numbers of
current cases and increasing therapeutic expectations.
The clinical standards, as drafted, are a good blend of prevention,
protection and treatment of disease. Overall, the College supports
its general approach. There are, however, problems and challenges:
-
The ambition of the Clinical Standards should be set at a much
higher level, both of standards and expectations. Throughout
the text, there are 75%, 90%, 95% expectations of several parameters. Patients
should expect, through partnership and care, levels of intervention
in various respects nearer to 100%, especially in areas of crucial
clinical protocols. Figures much less than 100% may
be pragmatic, but are less than ideal for public assurance.
-
The grading
of services from A-D for a long-term condition
such as HIV runs the risk that patients will perceive that, in a
lower graded service, they are relating to one that performs less
well than those rated more highly. While Health Boards have
to make decisions about investment and the support of good clinical
standards, they may run the risk that low expectations, or higher
expectations that are not met, may have consequences for the NHS Board
in the longer term.
-
A general issue is the impression that clinical standards
are not closely involved in the primary care element of HIV services. General
practice provides the continuity and context for the patient, their
relationships and family over time, in dimensions that specialist
services usually cannot. It is essential that combined and
integrated care of people with HIV incorporates primary care. Systems
such as QOF demonstrate that primary care can sustain high levels
of involvement in care relating to diseases of public health importance.
Specific points:
The framework of quality standards is strong and we support its overall
scope and layout.
1. Organisation and Delivery
of HIV Services
For the most part, the standards are sensible.
1.8 We are concerned by the quality statement "a
minimum of 80% of patients attending HIV specialist services are
in shared care with their GP". This falls short of the BHIVA
Standards 2007 in which a detailed description of Primary Care
involvement in HIV management is provided. The QIS Standard implies
that one in five patients could be disadvantaged by lack
of involvement of their GP in their care.
2. Training, Competency
and Workforce Development
This is well structured. However, statement 2.8 on the
diploma in HIV for newly appointed consultant staff is inconsistent
with JRCPTB Standards for training, and this discrepancy should be
reconciled.
3. Primary Prevention
of HIV
This section addresses the opportunities for reducing HIV transmission
in a range of social settings. Most of the standards are reasonable.
3.6 The College has misgivings about the quality
statement regarding post-exposure prophylaxis following sexual exposure -
PEPSE. Does any study show benefit from PEP? The evidence
was reviewed by Bryant and colleagues in Health Technology Assessment 2009,
Volume 13, No 14. On page 14 of that publication, "the
results suggest that PEP made no difference to the expected sero-conversion
to HIV for this cohort". Neither this HTA or Schechter's
paper from Brazil have been cited by QIS. Is QIS setting a standard
for Health Boards to implement an unlicensed use of antiviral drugs
when no evidence exists to demonstrate its efficacy?
3.7, 3.11, 3.14 All 3 Standards refer
to provision of condoms. In our view one standard would suffice.
4. Prevention for People
Living with HIV
This section is one that the College would strongly support.
5. Behavioural Interventions
This section contains considerable repetition, and promotes the risk
that several standards are not reliably measurable. If we accept
the concept of an A-D grading system as effective, perhaps just
one standard per grade would be appropriate.
6. Identification of Asymptomatic
HIV Infection
6.2, 6.6 The D Standard (6.2)
appears to be more demanding than the C Standard (6.6) -
the contrast with any patient with more than 95% of patients suggests
that coverage should be universal for a lower standard of expectation
of service.
6.7 There
appears to be insufficient protection for children. We believe
that all children
with a high risk of HIV should be tested.
6.10, 6.13 These are likely to be influenced by local
demography that is outwith the control of the Health Board. Although
a Standard that encourages early detection and entry into services
is laudable, it would be more helpful to specify that Boards should
review CD4 count at diagnosis to guide where to concentrate testing
initiatives.
7. Identification of Symptomatic
HIV Infection
All of these statements appear to be sound.
The College would encourage universal testing for HIV for adults with
TB or lymphoma - that is, 100% coverage, and not 90%.
8. Management of HIV Testing
Process
The College supports the standards contained in this section.
9. Core Services
We support this section, but there is one shortcoming.
Statement 9.6 should be worded more strongly. It should
include a positive statement such as "Sharing the diagnosis of
HIV and the management plan with the patient's GP should be the norm. Reasons
for non-disclosure should be documented and regular, at least annual,
attempts made to facilitate disclosure."
10. Co-Morbidities of HIV
This section recognises the multi-system nature of HIV and the need
to share information with other health care staff including GPs. It
underlines the need to expect involvement of GPs as the norm in HIV
care.
10.9 We are not aware of any link between HIV and prostate
cancer. Given the recent National Screening Committee statement
on PSA, the QIS standard would require stronger evidence to support
it. In addition, what test do screeners propose for anal cancer?
10.23 Assessment of neuro-cognitive function on an annual
basis might be insightful, but it is unlikely to influence clinical
management or benefit the patient or be attainable.
11. Antiretroviral Therapy
Most of these statements are acceptable.
11.12 "Home delivery of ART is available" is good
practice, rather than evidence-based for benefit, and also involves
primary care. Can we be clear that, to satisfy statement 11.18, "….
checks are carried out at each dispensing by a Specialist HIV Pharmacist
...", how ART is to be delivered at home?
11.15 on 'undetectable viral load' is a controversial
matter. The
aim of antiretroviral treatment is to bring HIV replication to a standstill. The
laboratory test measures the number of copies of viral RNA in 1ml of
venous blood. This is known as the "Viral Load". The
sensitivity of the test has improved in recent years and the lower
limit of detection is now between 20 and 50 copies per ml -
depending on which assay. Most clinical trials of antiretroviral
drugs look for an end point of less than 50 copies per ml. Most
clinicians would regard a Viral Load of 350 as a sign of treatment
failure. If QIS Standards reflect good medical care then the
statement should read "patients on treatment should have a Viral
Load consistently below 50 copies per ml". We
believe that setting the standard at 400 copies per ml is
not sufficiently stringent.
In summary, the proposed Clinical Standards are a major step forward
for HIV services in Scotland. Most of the draft QIS Standards
are those that we would support. Some, as outlined above, require
review and adjustment.
The general issue is that QIS may be missing an opportunity to embrace
primary care in the management of HIV. Contributions from primary
care in this respect should be weighted preferentially during the consultation.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[15 December 2010]
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