Substance users and HIV clinician’s perspective

1. Substance users and HIVclinician’s perspective Sarah Creighton Consultant GUM/HIV Homerton Hospital

2. Overview • Services in Hackney • Case histories

3. 2005 Among 38 substance users there were :- 12 homeless individuals 18 sex workers 9 incarcerations 50 sexually transmitted infection 37 pregnancies 40 inpatient admissions (2 ITU) 12 CD4 < 200 14 lost to follow up

4. Service Provision • Multiple contact with health care providers • Single point of contact • Blood born virus team -phlebotomy, adherence support, side effect management, sexual health, delivery of medication, liaison with HIV clinic, Interferon • Outreach team • Supportive Hostels • HDM and DOT

6. Deaths

7. CW • 20 yo f HIV + 2000 TB 2004 • Nadir CD4 30 VL 1 million 30/12/2004 • 3 pregnancies • Mother and baby unit 2007 • ARV truvadaatazanavir CD4 275 VL 98 • Assault, prison • Asthma treated with fluticasone • Iatrogenic Cushings, brittle diabetes • Psychiatric admission • RIP 2008 insulin overdose • Learning point – issues with multiple agencies

8. RP • 41 yo F HIV + 2009 Hep C • Positive Elispot – PTB • CD4 605 3/12 TB treatment • Rehoused out of area, LTFU • 2011 DTB, CD4 11 albumen 17 weight 30 kg • 6/12 treatment. Interstitial nephritis. LTFU • TB reactivated 10/6/12 CD4 83. Still in hospital • Learning point – ARV support impossible without substance support

9. CC • 44 yo MHIV + 2005 St Elsewhere.TB, hep C, LTFU • Jan 2008 Homerton CD4 110 • Ataz/r/tru • Nov 2008 – CD4 361 VL < 40 • Jan 2009 GP noted to be out of area • Methadone support transferred • May 2011 metastatic Ca lung supportive care • Learning point – need to battle for ‘special dispensation’

10. DL • 42 yo M HIV + 2005 St Elsewhere LTFU • ITU 2010 TB PCP pseudomonas Hep C PN • CD4 95 VL 167664 • LTFU; Home visit; • RV 47 yo F Hep C CD4 195 VL 94954 • 2013 DL VL 1 CD4 334 RV VL < 40 CD4 441 • Learning point invest in self esteem

11. LB • 24 yo F HIV + 2005 TB 2006 Butane addict • 3 x pregnancy • Nadir CD4 863 peak VL 190 000 • Reckless transmission case • Started heroin, rapid deterioration • Street homeless, severe HSV CD4 528 • Learning point social structures hold things together

12. AC • 17 yo f HIV + 2010 CSA • CD4 699 VL 7094 • Mother disowns her • ‘friends’ give heroin ‘for free’ • Large investment in development work • 2012 in college, CD4 842 drug free • Learning point importance of social support

13. PB 32 GL 23 FA 40 DD 45 CF 39 AM 39 VA 34 NS 27 CW 30 MO 41 CM 46 JLD 41 RB 35 MF 33 LB 30 OW 32 SS 30 DML 35 BB 35

14. PB 32 GL 23 FA 40 DD 45 CF 39 AM 39 VA 34 NS 27 MO 41 CW 30 CM 46 JLD 41 RB 35 MF 33 LB 30 OW 32 SS 30 DML 35 BB 35 RIP

15. PB 32 CW 30 GL 23 FA 40 DD 45 CF 39 AM 39 VA 34 NS 27 MO 41 JLD 41 RB 35 MF 33 LB 30 OW 32 SS 30 DML 35 BB 35 CM 46 RIP disability

16. PB 32 CW 30 GL 23 FA 40 DD 45 CF 39 AM 39 VA 34 NS 27 MO 41 JLD 41 RB 35 MF 33 LB 30 OW 32 SS 30 DML 35 BB 35 CM 46 RIP disability lost

17. PB 32 CW 30 GL 23 FA 40 DD 45 CF 39 AM 39 VA 34 MO 41 NS 27 CM 46 RB 35 MF 33 LB 30 OW 32 SS 30 DML 35 BB 35 JLD 41 RIP disability lost V unwell

18. Summary 38 3 LTFU 31 new registrations 2 LTFU 9 RIP 2005 24 active cases 11 poor adherence 2013 55 active cases 4 poor adherence

19. Learning Points • Flexibility • Use of wider medical structures • Single point of contact • Social structures • Prison • Housing • Lay structures • Investment in self esteem