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Annual health review for people living with HIV 

  • This Guidelines for Nurses summary highlights the key points for primary care, please refer to the full guideline for the complete set of recommendations

Cardiovascular health

Bone health

Renal health

Sexual and reproductive health and psychosexual wellbeing

Mental health and psychosocial wellbeing

Antiretroviral therapy (ART) and non-ART management

Preventative medicine

Monitoring of comorbidities

Neurocognitive impairment

 

Standard 1 Cardiovascular health

  • All people living with HIV should have a cardiovascular health check

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are competent and trained in cardiovascular risk assessment

Process

  • Annual measurements of blood pressure, lipid profile, QRISK2 score or other validated tool (for people ≥40 years of age), plus advice on a healthy lifestyle

Outcomes (for those who manage blood pressure and lipids)

  • Optimised management of hypertension
  • Optimised management of dyslipidaemia
  • Reduced modifiable cardiovascular disease risk

Outcomes (for those who do not manage blood pressure and lipids)

  • Increased number of people with hypertension who are engaged with their provider for hypertension management and optimisation
  • Increased number of people with dyslipidaemia who are engaged with their provider for lipid management and optimisation

Example questions

  • Have you experienced dizziness or headaches?
  • Do you get short of breath on exertion?
  • Has your diet changed in the last 12 months?
  • Do you undertake regular physical activity?
  • Would you like to be referred to smoking cessation? (if appropriate)

Supporting self-management for this standard

  • Diet and physical activity management
  • Check for non-antiretroviral therapy medicines and side-effects
  • Smoking cessation (if appropriate)
  • Offer health education/promotion leaflets on blood pressure, suggest apps to monitor lifestyle management (e.g. diet, physical activity)

Information for people living with HIV

  • How to reduce and/or manage hypertension
  • Beliefs and benefits of treatment
  • Setting goals for change and enabling people living with HIV (PLHIV) to make a plan about reducing risk
  • Make aware that heart disease can be prevented through effective action on modifiable risk factors: sedentary lifestyle, hypertension, smoking, stress, obesity, diabetes, dyslipidaemia

Standard 2 Bone health

  • All people living with HIV and 50+ years old should be monitored and assessed for osteoporosis and risk of fractures

Structure

  • Evidence of local arrangements that nurses working in the field of HIV care know when to refer for, and have access to, dual-energy x-ray absorptiometry scanning and are competent and trained in the assessment of osteoporosis and fracture risk assessment

Process

  • Annual measurement of FRAX score and recorded history of falls and low-level (impact) fractures in all PLHIV >50 years. PLHIV at increased risk of fracture should have their bone mineral density (BMD) measured, their vitamin D/parathyroid hormone status assessed and optimised, and antiretroviral therapy (ART) and other medication reviewed. In addition, measure height (sign of vertebral collapse if decreasing)

Outcomes

  • Optimised bone mineral density in those people with osteopenia/osteoporosis or at risk of a fracture

Example questions

  • Follow the FRAX assessment form for specific questions

Supporting self-management for this standard

  • Regular physical activity, diet, and medication optimisation
  • Offer health education regarding lifestyle management, e.g. increase weight-bearing exercise, avoid excess alcohol, smoking cessation, aim for 700 mg/day calcium—refer to: www.nos.org.uk/for-people-and-families/healthy-living-and-risk/healthy-eating/ so people can calculate their calcium intake for themselves
  • Advice on increasing vitamin D level—20–30 minutes of sunlight on forearms daily throughout summer, oily fish/egg yolks/liver/wild mushrooms to increase vitamin D through diet
  • Advice on steroids increasing risk of osteoporosis

Information for people living with HIV

  • Advice/leaflets on how to optimise vitamin D exposure
  • Awareness of falls risk

Menopause and bone health

  • British HIV Association (BHIVA) and European AIDS Clinical Society (EACS) recommend 3-yearly bone fracture risk assessment using the FRAX tool in women aged >50 years, postmenopausal women, or women/those with other risks, e.g. excess alcohol intake
    • we have not included this measurement above (Supporting self-management) for this standard as this is an annual review. However, we recommend that the 3-yearly assessment is highlighted at the annual review, and a date planned and recorded for the bone fracture risk assessment

Standard 3 Renal health

  • All people living with HIV and chronic kidney disease (CKD) or post-kidney transplantation should have 6–12-monthly monitoring of their renal function

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are competent and trained in maintaining renal health and identifying possible chronic kidney disease

Process

  • All PLHIV with chronic kidney disease have their renal function and blood pressure monitored. In addition, lipid profile, body mass index, smoking status, antiretroviral therapy and other medications are reviewed annually. Kidney transplant recipients are reviewed at 6–12-monthly intervals with monitoring of renal function and CD4 cell count. All PLHIV to have a urine dipstick analysis to identify possible CKD

Outcomes

  • Early identification of kidney disease
  • Optimised clinical management (joint care or otherwise) of people with chronic kidney disease and people who have had a kidney transplantation including early referral to a renal specialist

Example questions

  • Have you experienced any sustained changes in the colour of your urine in the last 12 months?
  • Are you finding you urinate more or less than usual?
  • Do you use painkillers regularly (e.g. anti-inflammatories)?
  • Do you take any other medicines that you can buy over the counter or gym supplements?
  • If appropriate, ask about alcohol withdrawal

Supporting self-management for this standard

  • To be aware of drugs that can affect kidney function (e.g. non-steroidal anti-inflammatory drugs)
  • Lifestyle management and preventative risk factors

Information for people living with HIV

  • Practical advice on diet, management of blood pressure, hydration

Standard 4 Sexual and reproductive health and psychosexual wellbeing

  • All people living with HIV should be regularly screened for all sexually transmitted infections and have access to preventative interventions
  • All people living with HIV should be supported in establishing and maintaining health and enjoyable sexual lives for themselves and their partners, where applicable
  • All people living with HIV should have access to safe, effective, and acceptable methods of contraception

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are suitably educated and competent, trained in sexual health, and are competent in partner/contact notification or have access to these services

Process

  • Regular screening (depending on risk: 3–6-monthly or annually), recording and supporting people to protect themselves against sexually transmitted infections. Access and support for safe, effective, and acceptable contraception

Outcomes

  • PLHIV have healthy fulfilling sexual relationships if they want them
  • Increase in the identification and treatment of sexually transmitted diseases
  • Improved safe and acceptable contraception
  • Early identification of cervical pathology

Example questions

  • Are you having sex?
  • Are you having consensual sex?
  • Do you have pleasurable sex?
  • Is it a good relationship?
  • Do you feel safe at home?
  • Are you able to sustain an erection?
  • Was your last smear okay?
  • First day of your last period?
  • Do you have any pain/regular bleeding/spotting?
  • Are you planning a pregnancy?
  • Any menopausal symptoms?
  • Sometimes it can be difficult talking about safer sex; are you comfortable/confident discussing safer sex with partners?
  • (For people using drugs during sex): When was the last time that you had sex without drugs? [or use specific name for the drug(s) the person uses]
  • What contraception do you use?
  • Do you know your HIV status? (think Undetectable=Untransmittable)
  • When relevant, how easy do you find it to talk about HIV with new sexual partners?

Supporting self-management for this standard

  • Access to sexual and reproductive health care and information, as well as autonomy in sexual and reproductive decision-making

Information for people living with HIV

  • Health education for promoting a healthy and safe sexual experience and reducing incidence of sexually transmitted infections

Standard 5 Mental health and psychosocial wellbeing

  • All people living with HIV should have annual screening to identify psychological support needs
  • If required, all people living with HIV should be referred to appropriate services providing psychological support that delivers best practice using evidence-based guidelines

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are suitably trained and competent in screening and recognising mental health/psychological problems (including anxiety, depression, acute stress disorder, post-trauma distress) and potentially unhelpful coping responses (e.g. substance misuse, self-harm), and have access to pathways for support and treatment. Evidence that services providing psychological support for PLHIV are using assessment and intervention methods developed, standardised, and evaluated for use with HIV and other long-term medical conditions, or are relevant to the potential psychological presentations, as per the known evidence base pertaining to mental health issues in HIV

Process

  • Screening and referral for mental health and psychosocial wellbeing needs at annual review by nurses using evidence-based practice tools

Outcomes

  • Increased number of people identified who are living with psychological and emotional issues:
    • in the UK, the PHQ-2 and the GAD-2 for screening for anxiety and depression are free and widely used. The use of the wellness thermometer as an exploratory tool for psychosocial wellbeing issues is also available. Screening illustrates need, and outcomes will be dependent on identification of the relevant level of support

Example questions

  • Use a validated anxiety and depression screening tool
  • EACS recommends screening for depression every 1–2 years and advises on two main questions:
    • have you often felt depressed, sad or without hope in the last few months?
    • have you lost interest in activities that you usually enjoy?
  • Other psychological/emotional distress indicators/non-obvious signs of depression to look out for include: stress, burnout, angry outbursts, coping through work or alcohol

Note 1

  • EACS also recommends ruling out an organic cause (such as hypothyroidism, hypogonadism, Addison’s disease, non-HIV drugs, vitamin B12 deficiency)

Note 2

  • Referral to psychology services or a mental health team is a safe way to manage potential or actual mental health problems for PLHIV, especially for the inexperienced practitioner. Generic questions such as ‘Have you been experiencing any issues like anxiety or low mood that are affecting the way you live your life?’ may be related to the diagnosis and helpful to start a discussion

Note 3

  • It might be helpful to explore the issues of stigma and living with a chronic condition (people often say that these are major issues even if not clinically depressed/anxious). Questions such as: ‘Have you experienced any stigma or discrimination because of your HIV in the last 12 months?’ and ‘Have you experienced any issues managing your HIV care over the past 12 months?’ are useful to begin the discussion

Supporting self-management for this standard

Information for people living with HIV

  • To have their psychological needs assessed regularly and held in mind with regard to holistic care
  • Social, peer support information
  • Beliefs and benefits of treatment/support
  • Information about local services, e.g psychological, wellbeing

Risk

  • Health professionals delivering the annual health review should have accessed training regarding risk assessment and should use their local risk protocol to assess whatever risk is presented

Standard 6 Antiretroviral therapy (ART) and non-ART management

  • All people living with HIV on ART should have proactive management of side-effects and assessment of the efficacy of the therapy and identification of drug–drug interactions

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are supported by the multi-disciplinary team and are educated in the management of ART and identification of drug-drug interactions

Process

  • Annual assessment of drug–drug interactions, proactive side-effect management, appropriate monitoring of viral load to assess efficacy of therapy, support for self-management and drug regimen adherence

Outcomes

  • Improved control of HIV (as measured by viral load)
  • Improved quality of life
  • Improved self-management of medications
  • Reduction in drug–drug interactions and polypharmacy

Example questions

  • Most people accidentally miss or double-dose their HIV medication at times, how often do you find yourself doing this?
  • A lot of people take their medication late, how often do you find yourself doing this?
  • Generally, can you describe how well you take your medication?
  • Have you started on any treatment in the last 12 months, including over-the-counter medicines—specifically multivitamins and mineral compounds such as iron and calcium, or gym supplements?

Note

  • Careful consideration, understanding, and knowledge is needed on how to approach the topic of the use of illegal substances, recreational, party drugs, and chemsex. The person may be relieved to discuss the subject and it may uncover issues which could be affecting adherence/drug–drug interaction. Exploring concerns about any alcohol or drug use your patient might engage in is helpful but, if in doubt, or outside your scope of practice, then please refer to an appropriate professional

Supporting self-management for this standard

  • Adherence tools
  • Information on drug–drug interaction and adverse events of ART
  • Information on what to do if admitted to hospital, or if run out of, or lose ARTs
  • Information on drug resistance

Information for people living with HIV

  • Benefits of ART and improvement in quality of life

Standard 7 Preventative medicine

  • All people living with HIV should have access to preventative vaccines and interventions that reduce the incidence of illnesses

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are educated, trained, and competent at identifying vaccine-preventable illnesses

Process

  • Proactive assessment and risk-reduction strategies for PLHIV and vaccine-preventable illnesses

Outcomes

  • Reduced incidence of vaccine-preventable illnesses

Example questions

  • Do you know why it is important to be vaccinated against different viruses?
  • If you are going abroad do you know where to get your travel vaccines?

Supporting self-management for this standard

  • Lifestyle management regarding health-seeking behaviour
  • Check whether the vaccination plan is updated

Information for people living with HIV

  • Update information of free vaccines for risk groups
  • Benefits of risk-reduction for preventable illnesses and risk factors

Standard 8 Monitoring of comorbidities

  • All people living with HIV and non-AIDS comorbidities should be on a clear pathway for appropriate, safe, and effective management of care

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are coordinating care with the general practitioner or other healthcare provider to avoid duplication

Process

  • Clear protocols and pathways between primary and secondary care are essential for accountability, safe clinical management, and communication between healthcare professionals

Outcomes

  • Reduction in the progression of comorbid diseases
  • Improved quality of life

Example questions

  • Have you seen another doctor or healthcare professional in the last 12 months?
  • Have you talked about your HIV status with your GP or other service provider?
  • Is there anyone specifically you do not want to know about your HIV status?
  • Who manages your comorbidities (e.g. diabetes, COPD)?

Note

  • It is not expected or appropriate that all comorbidities are managed by the HIV specialist. Rather, we encourage a proactive approach to ensure that referral pathways are in place for specialisms, and integrated care pathways between primary and secondary care are effective. Allow communication (where appropriate) between HIV and specialties to provide holistic care. In addition, screen for infectious diseases (such as hepatitis C) if the person feels they have been at risk and do not wait for the annual health review

Supporting self-management for this standard

  • People are encouraged to have a GP with whom to work and coordinate health management. People will feel actively involved in health planning when working with their GP, and with a person’s consent a GP can work with the HIV providers to inform them of other specialists involved in the person’s care
  • Lifestyle management to reduce preventable long-term conditions. Provide advice on risk factors such as smoking cessation, diet, exercise initiatives (gym referrals via primary care)
  • Encouraging people to search out strategies to manage co-morbidity, such as Telehealth or websites (e.g. www.nhs.uk/Livewell/Diabetes/Pages/Avoiddiabetes.aspx)

Information for people living with HIV

  • Reassurance that referrals/communication with other specialities has/will take place
  • Awareness of family/caregiver of signals to be alert to and know what to do

Standard 9 Neurocognitive impairment

  • All people living with HIV should have access to cognitive screening on an annual basis

Structure

  • Evidence of local arrangements to ensure that nurses working in the field of HIV care are trained and competent in screening for cognitive difficulties.* Evidence of pathways in place for referral for further screening and in-depth cognitive assessment

Process

  • Screening as a routine part of the annual review with established pathways for referral

Outcomes

  • Improved early detection of cognitive difficulties
  • Improved early assessment and interventions for people with cognitive difficulties

Example questions

  • Use a validated screening tool
  • *Screening with three questions (as recommended by EACS) could be used as follows:
    • do you experience frequent memory loss (e.g. do you forget the occurrence of special events even the more recent ones, e.g. appointments)?
    • do you feel that you are slower when reasoning, planning activities, or solving problems?
    • do you have difficulties paying attention (e.g. to a conversation, a book, or a movie)?

Note

  • When using a validated screening tool it should be administered by a suitably qualified practitioner or a healthcare professional who has received training and is accessing ongoing support to deliver screening assessments

Supporting self-management for this standard

  • Lifestyle management for reduction of preventable neurocognitive risk factors
  • Encouraging people to search out strategies to manage cognitive difficulties perhaps from websites (e.g. reputable sites for issues such as brain injury, dementia)
  • Consult with significant others to establish whether they have noticed any changes

Information for people living with HIV

  • Information relating to local services (e.g. access to neuropsychological assessment, neurorehabilitation, or peer support, e.g. charity organisations supporting people with cognitive problems)
  • Up to date information on HIV and possible cognitive impairment
  • Information on other preventable neurocognitive risk factors (e.g. alcohol, smoking, drug use, hepatitis C, neurosyphilis)
  • A useful fact sheet regarding HIV and cognitive changes can be found here:
  • Advise the use of a diary to help with any memory problems and seek advice from recognised support groups if there are any concerns about cognition

full guideline available from…

www.nhivna.org/annual-health-review-for-people-living-with-HIV

Annual health review for people living with HIV. A good practice guide. May 2018. 

First included: July 2018.