Using implementation science to support the adoption of routine HIV testing in a suburban emergency department

Background: Implementation science (IS) involves using techniques to promote implementation of evidence-based guidance to improve healthcare quality and outcomes. Sutton has an HIV prevalence rate of 2.5/1000 and a high late diagnosis rate. Testing in emergency departments (ED) has been shown to be effective and has been adopted in many UK metropolitan centres. Routine testing in EDs of high prevalence areas is recommended by NICE. Method(s): Our project started in November 2019 and was designed to promote uptake of opt-out HIV testing into routine practice through education, training, and incentives. Strategies employed outlined in table 1. We assessed acceptability and adoption of the guidance. Result(s): HIV testing increased from average 7.5 tests/ month to 592 tests/month (17,165 tests in 28 months). Three previously undiagnosed people and 1 individual with a known diagnosis who had disengaged were identified. Testing numbers ranged from 191-1229/month. Numbers dropped during the following challenging periods: 1. Tendering of the sexual health service 2. IT and sample processing issues on implementation 3. Emergence of SARS CoV-2 4. Blood bottle shortage in 2021 Conclusion(s): This project demonstrated that while implementation of routine opt out HIV testing in ED is feasible and acceptable, it took a long time for the practice to be embedded and it was easily de-railed by external circumstances. Acknowledgements- This project was conducted with support from an Implementation Science grant by ViiV. (Table Presented).

A collaborative approach to research study recruitment in PLWH during the SARS CoV-2 pandemic

Background: Since COVID there are fewer site investigator meetings for non-CTIMP studies to discuss recruitment barriers. Additionally, literature highlights various research trials that have successfully recruited do not report their strategies, consequently impacting ability to learn from success. The pandemic has had considerable impact on enrolment to clinical research, thus services have needed to revaluate their approach. Following the pandemic, patients report more likely to engage in research if offered remote or combined visits. Method(s): We reviewed recruitment strategies at our clinic for two observational studies with large targets (SCAPE-HIV, Positive Voices). SCAPE-HIV, a prospective study exploring immune responses of PLWH to SARS CoV2 infection and vaccination. Positive Voices, a crosssectional questionnaire study. Minimum recruitment targets, 600 and 262 respectively. SCAPE involves open-offer enrolment, Positive Voices from a defined pre-selected cohort. Initial approaches identified people opportunistically at clinic visits, with research staff offering information. However, reaching our targets through COVID became challenging and a move to virtual appointments condensed our opportunities to approach. To increase recruitment, engagement and training of NHS nursing and clinical staff was undertaken alongside remote patient contact. Result(s): After implementing collaborative methods, Positive Voices recruitment increased to 170 in July/ August 2022 (73 in May/June). SCAPE recruitment also improved. Hybrid nurse practitioners dedicating time to approach people during clinic visits and clinic staff involvement attributed to this rise, representing over half of consents (Table A). The clinic team's substantial knowledge of our cohort, combined with their openness to research, leads to greater understanding of how likely individuals are to accept studies. Conclusion(s): Positive Voices and SCAPE-HIV studies have been successful with recruitment due to a collaborative approach, resulting in our site being the highest current recruiting site involved in Positive Voices. This approach has helped motivate the NHS team to become more involved and has become an exemplar for clinical trial delivery within our Trust. (Table Presented).

Managing metabolic issues: Evaluation of a short-term comparative implementation project introducing a dietitian to an HIV service

Background: Persons living with HIV (PLWH) face a number of nutritional issues including dyslipidaemia, non-alcoholic steatohepatitis, diabetes, and obesity that can be attributed to HIV infection/medications. Poor management of these complications can reduce quality of life and increase health costs. We implemented a dietetic service within our HIV clinic for 6 months and evaluated the outcomes. Method: Twice weekly dietetic clinics were established. Eligible patients were offered group, face-to- face or telephone consultations. Medical records and our database were used to obtain demographics, treatments and co-morbidities. Cholesterol markers were measured along with weight, height, and body mass index (BMI). Results: 84 (total clinic cohort 3308) PLWH were referred. 61/84 attended their appointment;36 selected face-to- face, 25 selected telephone for their first appointment. Patients did not opt for group sessions. DNA rates were similar in both groups (31% and 28% respectively). In attendees median age was 54y, 59% male, 34% Black African origin. Eighty-five per cent of patients were diagnosed before 2010. 95.1% had undetectable viral load and 82% had CD4 count ≥400 cells/mm3 at most recent consultation. 82% of patients were on ≥1 NRTI and 36% were on a PI. Major reason for referral (40/61) was weight management;other reasons included type II diabetes management (7/61), irritable bowel syndrome (IBS) (8/61) and poor appetite (5/61). 15% of patients had an HbA1c of ≥48mmol/L and 11% of patients were pre-diabetic (HbA1c 42-48 mmol/L), 50% had TChol>5.0mmol/L, 11% had TChol:HDL ratio >5 and 38% had a LDL level >3mmol/L. Of the patients with available BMI, 32% (13/41) were classed as overweight and 56% (23/41) were classed as obese. 18% of attendees were ≥55y female and post-menopause could have been a contributing factor for weight gain. 28% of telephone and 31% of face-to- face consultations were scheduled for at least one follow up. Conclusion: PLWH are at risk of complex metabolic conditions, which can be difficult to manage. A dietician was able to provide expert and personalised advice to our patients and helped to empower them to take care of their own health. Patients engaged with both telephone and face-to- face consultations. Due to the short-term funding available in addition to the COVID-19 pandemic, longer term impact could not be evaluated.

The pandemic, lockdow, and their impact on admissions for patients with HIV

Background: At the start of the UK national lockdown in March 2020, many of the most vulnerable patients with HIV were encouraged to shield, and HIV outpatient services were forced to remodel. We aimed to look at: first, how emergency admissions for patients with HIV had changed in 2020 in comparison with previous years and during/after lockdown;second, to examine whether any fall in admissions related to vulnerability factors (new diagnoses, CD4<350, other HIV-related presentations). Finally, to see if the spectrum of presentations had changed. Method: Retrospective analysis of databases covering HIV admissions for two hospital sites in our urban trust was performed for matched time period (March -August) for 2017-2020. Elective and maternity admissions were excluded, as well as patients who did not have a recorded CD4 count either during the relevant admission or in the 18 months prior. Results: Admissions fell for the period of March to August 2020 compared with previous years (see table). There were 7 covid admissions. A spike in admissions was seen in June, but admissions fell again in July and August. Patients with low CD4 counts (<350) accounted for a similar proportion of total admissions in 2020 (47.8%) compared with previous years (47.0%). Although admissions directly related to HIV fell slightly in 2020 (11, compared with an average of 16), they came to represent a slightly higher proportion of admissions (16.4%) compared with previous years (average 13.8%). This was one of only two admission categories which proportionately increased in 2020. Conclusion: The fall in admissions during lockdown was to be expected. However, although numbers rebounded in June, this did not continue in July and August. There are numerous potential explanations for this. The reduction in emergency admissions for patients with a low CD4 count is of particular concern;the impact of this on morbidity or mortality remains to be seen. (Table Presented).

Pharmacist-led antiretroviral therapy (ART) switch during a pandemic: Improving patient safety and reducing footfall in a London tertiary centre

Background: The COVID-19 pandemic mandated reduced face-to- face consultations/monitoring for our people living with HIV (PLWH). Eviplera (EVI) has a low genetic barrier to resistance and drug-drug interactions (DDIs) that may lead to virological failure (VF). We have had 23 known DDI related VFs between 2012-2018. Stringent food requirements may also reduce compliance. The commissioning of Delstrigo (DEL) presents an option for stable PLWH receiving EVI to switch to a regimen without food requirements, a higher barrier to resistance (in vitro) and fewer DDIs. A dedicated pharmacist contacted PLWH receiving EVI to counsel them regarding a remote DEL switch. Method: Clinician lists were obtained of PLWH on EVI and screened for switch suitability. A pharmacist undertook a telephone consultation with eligible patients due for a follow- up between September-November 2020. Patient decision was recorded and conveyed to the treating clinician prior to routine appointments. A follow-up survey was sent via SMS to all patients to record satisfaction scores. Post-switch, a follow-up was planned to look at viral outcomes and other safety/tolerability parameters. Results: 135 patients were found to be on EVI at our site. 23 patients from three clinicians were deemed appropriate for pilot consultation. 19/23 (82.6%) agreed to DEL switch. 16 responded to survey;14/16 (87.5%) of patients reported being either satisfied or very satisfied with a pharmacist-led switch. 15/16 (94%) would opt for future consultations with pharmacists. 57% (13/23) of patients were successfully switched at the time of writing. Of the patients who were switched and followed up, 100% continued on DEL. 6/13 (46%) had a complete follow-up. Of the six who have had follow-up, 100% remained virologically suppressed. Conclusion: The pilot improved patient safety, reduced footfall and offered patients choice. Switching to DEL currently represents a cost saving compared to continuing EVI. Lack of food restriction was the most popular switch incentive for patients. Pharmacist-led switches are safe, efficient and can improve patient care alongside saving costs.