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Substance users and HIVclinician’s perspective
Sarah Creighton
Consultant GUM/HIV
Homerton Hospital
Overview
• Services in Hackney
• Case histories
2005Among 38 substance users there were :-
12 homeless individuals18 sex workers9 incarcerations50 sexually transmitted infection37 pregnancies40 inpatient admissions (2 ITU)12 CD4 < 20014 lost to follow up
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
2005 2007
N 38 47
Lost 14 3
Needing HAART 19 22
Receiving HAART 8 20
DeathsCD4 VL Cause of death
CW 275 98 OD
SS 895 13000 lymphoma
HH 670 135 CCF
CC 361 <40 Ca lung
CA 219 <40 cirrhosis
RT 210 430000 CRF
JD 610 4000 RTA
RA 315 410 Surgical comp
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 truvada atazanavir 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
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
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’
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
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
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
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
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
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
disability
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
disability
lost
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
disability
lost
V unwell
Summary38 3 LTFU31 new registrations 2 LTFU9 RIP
2005 24 active cases 11 poor adherence2013 55 active cases 4 poor adherence
Learning Points
• Flexibility• Use of wider medical structures• Single point of contact• Social structures
– Prison– Housing– Lay structures
• Investment in self esteem
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