Does general practice deliver safe primary care to people living with HIV? A case-notes review.

BACKGROUND: Safe care in general practice for people living with HIV requires early diagnosis of undetected infection and safe co-prescribing with antiretroviral therapy (ART). AIM: To evaluate safe co-prescribing in general practice patients who are taking ART, and to describe missed diagnostic opportunities for undiagnosed HIV infection in primary care. DESIGN AND SETTING: Retrospective case-notes review in general practices within NHS City and Hackney Primary Care Trust (PCT), London, UK. METHOD: All general practices in NHS City and Hackney PCT were invited to participate. Patients known to be HIV positive were identified using Read Codes. Each practice undertook retrospective case-notes reviews on specialist correspondence, coding of ART, prescribing of common contraindicated drug pairings, and missed opportunities for HIV diagnosis. RESULTS: In total, 31/44 (70.5%) practices participated, and 1022 people living with HIV were identified. Practices had received HIV clinic letters for 698 of those 1022 (68.3%) patients in the previous 12 months. Of the 787 patients known to be prescribed ART, only 413 (52.5%) had correct drug codes recorded; 32/787 (4.1%) were receiving specified contraindicated drug pairings. In total, 89 patients were eligible for their case-notes to undergo a retrospective review of occurrences that took place pre-diagnosis. In the 2 years preceding diagnosis, these 89 had attended 716 face-to-face GP consultations, of which 123 (17.2%) were for indicator conditions. Fifty-one of these patients (57.3%) presented at least once with an indicator condition (interquartile range 1-3; median 2). CONCLUSION: In a large-scale evaluation of GP records of people living with HIV, gaps in ART recording and co-prescribing were identified, and evidence demonstrated missed opportunities for diagnosis within general practice. Specialists and generalists must communicate better to enhance safe prescribing and reduce delayed diagnosis.

Population structure and genetic diversity of the parasite Trichomonas vaginalis in Bristol, UK.

The protozoan parasite Trichomonas vaginalis is the causative agent of trichomoniasis, an extremely common, but non-life-threatening, sexually-transmitted disease throughout the world. Recent population genetics studies of T. vaginalis have detected high genetic diversity and revealed a two-type population structure, associated with phenotypic differences in sensitivity to metronidazole, the drug commonly used for treatment, and presence of T. vaginalis virus. There is currently a lack of data on UK isolates; most isolates examined to date are from the US. Here we used a recently described system for multilocus sequence typing (MLST) of T. vaginalis to study diversity of clinical isolates from Bristol, UK. We used MLST to characterise 23 clinical isolates of T. vaginalis collected from female patients during 2013. Seven housekeeping genes were PCR-amplified for each isolate and sequenced. The concatenated sequences were then compared with data from other MLST-characterised isolates available from http://tvaginalis.mlst.net/ to analyse the population structure and construct phylogenetic trees. Among the 23 isolates from the Bristol population of T. vaginalis, we found 23 polymorphic nucleotide sites, 25 different alleles and 19 sequence types (genotypes). Most isolates had a unique genotype, in agreement with the high levels of heterogeneity observed elsewhere in the world. A two-type population structure was evident from population genetic analysis and phylogenetic reconstruction split the isolates into two major clades. Tests for recombination in the Bristol population of T. vaginalis gave conflicting results, suggesting overall a clonal pattern of reproduction. We conclude that the Bristol population of T. vaginalis parasites conforms to the two-type population structure found in most other regions of the world. We found the MLST scheme to be an efficient genotyping method. The online MLST database provides a useful repository and resource that will prove invaluable in future studies linking the genetics of T. vaginalis with the clinical manifestation of trichomoniasis.

Occurrence of Ixodiphagus hookeri (Hymenoptera: Encyrtidae) in Ixodes ricinus (Acari: Ixodidae) in southern Italy.

Natural enemies of ticks include the parasitoid wasp Ixodiphagus hookeri (Hymenoptera: Encyrtidae). The aim of this preliminary study was to investigate the occurrence of I. hookeri DNA in a community of ticks (Ixodes ricinus, Dermacentor marginatus, Hyalomma marginatum, Haemaphysalis inermis and Rhipicephalus turanicus). From May 2010 to March 2012, ticks were collected monthly by dragging and flagging, identified, and 481 adults and 305 nymphs screened molecularly for infection with I. hookeri. Of the samples tested (n=786), 3.1% (n=25) were positive for I. hookeri DNA, 7.2% (n=22) in nymphs and 0.6% (n=3) in adults. I. hookeri DNA was only detected in I. ricinus. This study shows that I. hookeri infests I. ricinus in southern Italy, with nymphs being the main developmental stage affected by this wasp.