key: cord-0041709-uaovdwv1
authors: nan
title: Poster Abstracts
date: 2017-04-04
journal: HIV Med
DOI: 10.1111/hiv.12513
sha: cc3fdeffeb7026efdd3cbb155673d70d7abd42a8
doc_id: 41709
cord_uid: uaovdwv1

nan

Background: A supra-regional prescribing algorithm (PA) for antiretroviral (ARV) drugs was imposed in our unit following a consultation process in April 2015. An audit of ARV prescribing was performed before and after this policy change and the results compared to evaluate ARV management and patient outcomes at the centre throughout this period of change. Other relevant changes also occurred during this time as newer ARVs became available and commissioned by NHS England. Methods: Retrospective case record review of patients starting ARVs for the first time in our centre before (Jan 2011-April 2014) and after (April 2015-16) the PA was introduced. We assessed whether treatment was consistent with BHIVA guidelines and the PA, those with undetectable HIV viral loads (VLs) and still on first line treatment (persistency) after starting ARVs and the cost savings achieved. In the first audit differences in prescribing patterns between consultants was also assessed, following the introduction of the PA this was no longer considered necessary and all prescribing members of the multidisciplinary team (MDT) were included. Results: Records from 180 patients were examined; 110 in the first and 70 in the second audit. Compliance with BHIVA guidelines was high; 92% and 97%. In the first audit there were only minor differences in consultant's prescribing practices. Following introduction of the PA only 6% were on the first line regimen (Kivexa/Efavirenz) and 76% on other PA regimens with justification for 81% and documented MDT in 63%. Those with an undetectable VL 6 months into treatment increased from 49% to 94% but persistency rates were similar. The largest changes in prescribing are the increase in use of lamivudine/abacavir; from 6% to 64% and integrase inhibitors (INI) from 10% to 84%; the single most commonly prescribed regimen was Atripla (32%) in the first audit and Triumeq (54%) in the second. Cost savings were of approximately £500 per patient per year. Conclusion: Significant changes in prescribing practice have been noted at our unit in the past 5 years with improvements in rapid virological control noted. As so few patients are on first line regimen of the new PA this is unlikely to be the reason; it is more likely the increase in use of INI, especially Triumeq. The cost savings from the PA introduction are modest and should be weighed against the increased need for MDT discussion for even straightforward prescribing decisions.

Background: While ATV-related nephrolithiasis is well reported, with an approximate incidence of 23.7 cases per 1000 patient years, Atazanavir (ATV)related cholelithiasis is only recently described. We report the case of a 47 year old white-British male, presenting with cholangitis due to an ATV containing gallstone. Methods: Following diagnosis in 1992, our patient started antiretroviral therapy in 1999. At presentation he had been on Truvada. ATV-Ritonavir for 6 years. His admission CD4 count was 443 cells/mm 3 (39%) with a non-detectable viral load (<20 copies/ml). The patient presented with right upper quadrant pain, fevers and jaundice and treated for biliary sepsis. Magnetic Resonance Cholangiopancreatogram (MRCP) confirmed gallstones and possible sludge in the distal common bile duct with duct dilatation. At Endoscopic Retrograde Pancreatogram (ERCP, despite sphincterotomy, the 5-8 mm common bile duct stone could not be removed and two 9-12 mm balloons burst on contact with the stone. After a third balloon impacted the stone, attempted stent insertion failed. At a second ERCP three days later the stone was successfully removed with a dormia basket. As a consequence of concerns regarding ATV gallstones, his medication was changed to Truvada, Darunavir-Ritonavir. Results: The stone was sent for ATV drug level analysis using a validated HPLC-MS methodology. Macroscopically it was a single brown stone. It was dissolved in 4.5 mls of 0.9% normal saline before it could be weighed, based on size and estimated specific gravity, we estimate a weight range of 130-540 mg. Stone ATV concentrations were estimated at 125-520 lg/mg. In comparison, typical concentrations of ATV (300/100 mg formulation) in nonpregnant HIV+ patients at steady-state are reported as a geometric Cmin of 700-1500 ng/mL, and Cmax of 4000-5500 ng/mL. Conclusions: Our case represents the first measurement of ATV stone concentration in a patient presenting with gallstones while still on long-term ATV, and suggests much higher stone concentrations of ATV than previously reported. From the gastroscopist's point of view, we would highlight the unusual feature that several balloons burst easily on contact with the stone. As patients remain on ATV for longer periods, vigilance for ATV associated cholelithiasis should be maintained, even after stopping the drug. ERCP operatives may find ATV containing bile duct stones better removed with Dormia baskets rather than balloons.

Clinical outcomes of naive patients started on darunavir/ cobicistat-based ART: experience from a clinical setting F Clark, D Cousins, N Lomax, S Warren and S Attridge Cardiff Royal Infirmary, UK Background: A fixed dose combination pill containing darunavir and cobisistat marketed as Rezolsta â was approved for use in Welsh HIV clinics in August 2015. This offers a fixed dose protease inhibitor option and reduction in pill burden for patients. However, patients and providers may be concerned about efficacy, safety, tolerability and impact on measurement of renal function. Methods: Patients started on first line antiretroviral (ARV) therapy containing Rezolsta â between June 2015 and November 2016 were identified from pharmacy records. Data was collected on demographics, baseline characteristics, ARV and other drug history. Data was also collected on clinical parameters along with renal function and patient reported side effects. Results: 22 notes were identified as eligible for inclusion. Many patients were male (90%) and the median age was 32 years. Median time between diagnosis and start was 1 month (range 0-188) with a median nadir CD4 count of 280 cells/mm 3 (range 80-550). 2 patients (9%) had documented archived resistance prior to starting. All patients were commenced on a tenofovir containing backbone. An undetectable viral load was achieved by 24 weeks in 90% of patients (median 12 weeks). The median change in estimated GFR at 4 weeks was 0 ml/min. 8 patients (36%) reported side effects which included rash, nausea, vomiting, diarrhoea and headaches. However all resolved within 2 weeks and no patients switched/stopped treatment due to side-effects. 17 patients started a Rezolsta â based ART prior to resistance test results and once the result was known 2 patients switched therapies to reduce drug interaction and 1 switched for STR choice. 19/22 patients (86%) continued on their initial Rezolsta â based ART. Conclusion: The majority of na€ ıve patients using Rezolsta â achieved an undetectable viral load within 24 weeks. A switch in 3 patients suggests other regimens with different side effect profiles and pill burdens are an option but 86% continued on their Rezolsta â based ART. No patients who started prior to a resistance test result had to be switched due to transmitted drug resistance. The tolerability of the short lived side effects was widely observed. The absence of eGFR change seen in this patient cohort leads clinicians to have a low threshold of concern for monitoring renal function. This data supports the benefits of starting a simplified regimen such as Rezolsta â , and also offers a safe and financially viable option for healthcare providers.

Methods: Patients started on Rezolsta between 4 March 2015 and 24 November 2016 were identified from pharmacy records and the case notes reviewed. Data was collected on demographics, baseline characteristics, antiretroviral and other drug history and indications for switch. Data was also collected on clinical parameters after switch along with renal function and patient reported side effects. Results: 77 notes were identified as eligible for inclusion. 54 patients were male (70%) and the median age was 44 years. 2 patients (3%) had documented archived resistance. 56 patients (73%) had a tenofovir-based backbone. Reasons to switch to Rezolsta varied with the majority of patients switching for simplification, n=57 (74%). 10 patients switched due to low level viraemia on previous regimen (13%), 8 patients switched due to side effects on previous regimen (10%) and 1 patient switched due to ritonavir allergy. Loss of virological control occurred in 1 patient. 17 patients had an improvement in their eGFR by an average of 6 mL/min. 18 patients had a decline in their eGFR of an average of 9 mL/min at first blood test. Side effects include on going diarrhoea, nausea and vomiting, rash, vivid dreams, sweats, dry mouth, headaches and muscle pain; however the majority being shortlived (2-4 weeks). 7 patients (9%) stopped taking Rezolsta due to nausea, size of tablet, muscle pain, hepatitis C interactions, personal preference for alternative regimen and poor memory/concentration. Conclusion: Most patient's experience of switch to Rezolsta was uneventful but 5 returned to their previous regimen and 2 switched to another regimen. The tolerability of the drug and improved patient outcomes was widely observed. The minimal changes in eGFR seen in this patient cohort leads clinicians to have a low threshold of concern for monitoring renal function. This data supports the benefits of a simplified regimen such as Rezolsta, and also offers a safe and financially viable option for healthcare providers.

Early UK and Ireland patient access to tenofovir alafenamide-based products through a compassionate use programme C Robinson 1 , G Reilly 1 , A Smith 1 and D Piontkowsky 2 1 Gilead Sciences Ltd, London, UK, 2 Gilead Sciences, Inc., Foster City, USA Background: Pre reimbursement access can benefit patients with unmet need. Following presentation of phase 3 clinical trial results for tenofovir alafenamide (TAF) based products, Gilead Sciences was approached for early access. Gilead made available 3 products elvitegravir/cobicistat/emtrictabine/ TAF (Genvoya), emtricitabine/TAF (Descovy) & rilpivirine/emtrictabine/TAF (Odefsey) through a compassionate use programme (CUP). TAF products were studied in treatment na€ ıve and switch adults, adolescents, and renally impairment (eGFR ≥30 mL/min) and measures of renal markers and bone mineral density showed improvement with TAF compared to tenofovir disoproxil fumarate (TDF) regimens. Methods: Cases for CUP use were assessed on an individual basis, with internal clinical review. A database was established including gender, age, rationale for request, co-morbidities, co-medication, resistance, current viral load/CD4 count, HBV/HCV co-infection and recent laboratory results. This database has been scrutinised to review demographics of applicants and clinical rationale. Results: 573 patients accessed TAF based products via the CUP, with the demographic breakdown, compared to the UK HIV population, in the The most common clinical rationale for compassionate use were: 1. Declining renal function on tenofovir disoproxil fumarate (TDF) 51% 2. Pre-existing renal impairment such that TDF or other NRTIs cannot be continued: 41% 3. High CV risk or previous CV event where an ABC use not desired by HCP: 56% 4. HLA B*5701 positive (ABC contraindicated): 9% 5. Declining renal function HBV/HIV co-infection where HBV/HIV therapy is required and a TDF based regimen is not suitable: 21% 6. Osteopenia/osteoporosis patients: 9%

Conclusions: The large scale of the CUP demonstrates that TAF containing products address significant unmet medical needs. All 3 TAF containing drugs are now commissioned across the UK and Ireland. For patients with impaired renal function or reduced BMD, TAF offers a safer tenofovir-based treatment option. In the CUP, TAF based products seem to be of particular benefit in older patients in whom multiple co-morbidities are seen. Through a compassionate use programme, access is limited to those with significant unmet need; however clinical studies showed clinically relevant bone and renal advantages from adolescents through to older patients.

HIV clinic cohort re-audit after QIP I Cormack Croydon University Hospital, UK Background: Our department looks after >800 HIV positive outpatients in a high prevalence area with significant economic deprivation which has been shown to affect treatment outcomes. After an audit in 2013 I initiated a quality improvement project to review and improve anti-retroviral regimens for suitable patients. I re-audited my cohort during 2016. Methods: Prospective case note review and database completion on 308 HIV positive patients booked to attend their HIV physician during 2016. During that time 2 patients were lost to follow up, 2 died from non-HIV related causes (with a normal CD4, VL<40 copies/ml on HAART) and 4 transferred care (2 moved out of area, 2 transferred for specialist care). The non-attendance rate for this outpatient clinic was 11%. 68% of this cohort had been diagnosed late, 28% with AIDS defining illnesses (ADI) and 40% with baseline viral loads >100,000 copies/ml. 18% were diagnosed >15 years ago, 31%>10 years, 31%>5 years, 14% <5 years and 6% were newly diagnosed <1 year. Results: 282/300 (94%) were on HAART (82% on Home Delivery). 6 patients have been strongly advised to take HAART for medical reasons but decline (but are still engaged in care), 12 are asymptomatic and not ready to start and 2 are elite controllers VL<40 without HAART. 282/282 (100%) on HAART have a VL<200 copies/ml, 279/282(99%) <100 copies/ml, 272/282(96%) <50 copies/ml and 262/282(93%) <40 copies/ ml. 189/282 (67%) patients were on NNRTI/NRTI (157/282(56%) are on generically available NNRTIs).So far 100% of patients offered switch to generic NNRTI options have done so. 59/282 (21%) are on Protease inhibitors 42/282 (15%) are on Integrase inhibitors 4% patients are on novel HAART due to co-morbidities eg NNRTI,RAL,3TC. Compared to a previous audit in 2013 the number of patients on HAART has increased from 88% to 94%. NNRTI use has decreased from 72% to 67% but is still the most commonly used ART class in our cohort. Protease inhibitor use has decreased from 26% to 21% and Integrase use has increased from 2% to 15%. Conclusion: There was a high rate of retention in care and a low rate of nonattendance. Virological suppression remains very high in this cohort following prescribing changes with 82% on home delivery and the majority having generic options available.

Results: 48 patients (8F; 40M) were identified. The median age was 47 (range 28-80). 30/48 were White British. 30 were on boosted-PI monotherapy, the rest were on dual therapy with a boosted PI. The median duration on treatment was 154 weeks. 32(67%) on mono/dual therapy maintained virological suppression. 7(15%) stopped due to detectable viraemia, in whom 2 developed new resistance. The rest reverted to triple therapy and achieved virological suppression. 1 moved from dual to monotherapy due to archived resistance. It was discontinued later due to persistent viraemia with no new resistance. 8 (17%) stopped due to adverse events -3 lipodystrophy; 2 diarrhoea; 1 hyperlipidaemia; 1 drug interaction. 1 had neurocognitive impairment with detectable CSF viral loadsymptoms resolved after changing back to triple therapy. 37 patients took mono/dual therapy for ≥48 weeks; 7 transferred into care and their baseline investigations are unavailable: 5/30 (17%) at least doubled and exceeded the normal limit for triglycerides by 48 weeks. 2/30 (7%) had ≥10% decline in eGFR at 48 weeks. There were no statistically significant differences in eGFR or triglycerides between the mono and dual therapy groups. Conclusion: Mono/dual therapy with a boosted PI demonstrates comparable effectiveness and side effects within our cohort. It provides an alternative treatment strategy which simplifies treatment, avoids NRTI-related toxicities and reduces cost. Virological failure with new drug resistance remains a concern. Further long term data are required to support this in routine clinical practice.

Randomised trial of bictegravir or dolutegravir with FTC/TAF for initial HIV therapy PE Sax 1 , E DeJesus 2 , D Ward 3 , P Benson 4 , X Wei 5 , K White 5 , H Martin 5 , A Cheng 5 , E Quirk 5 and S Antonucci 6 1 Brigham and Women's Hospital and Harvard Medical School, Boston, USA, 2 Orlando Immunology Center, USA, 3 DuPont Circle Physicians, Washington, DC, USA, 4 Be Well Medical, Berkley, USA, 5 Gilead Sciences, Foster City, USA, 6 Gilead Sciences, London, UK Background: Bictegravir (BIC, GS-9883) is a novel, unboosted, once-daily INSTI that demonstrated potent activity in a 10-day monotherapy study and has in vitro activity against most INSTI-resistant viruses. Methods: Treatment na€ ıve, HIV-infected adults were randomized 2:1 to receive blinded treatment once daily with BIC 75 mg or dolutegravir (DTG) 50 mg with open label emtricitabine 200 mg/tenofovir alafenamide 25 mg (FTC/TAF) for 48 weeks. The primary endpoint was the proportion with HIV RNA <50 c/mL at W24 using snapshot analysis. Noninferiority was assessed through 95% CI at W24 and W48. Safety was a secondary endpoint. Results: Of 98 patients enrolled, 65 were randomized to BIC+FTC/TAF and 33 to DTG+FTC/TAF. Most subjects were male, had asymptomatic HIV infection, with median HIV-1 RNA 4.4-4.5 log10. Virologic success (HIV-1 RNA <50 c/ mL) at W24 was 97% for the BIC arm and 94% for the DTG arm, and at W48 was 97% and 91%, respectively (Table) . No viral resistance was detected in the BIC+FTC/TAF arm. There were no treatment-related serious adverse events and no deaths. One subject in the BIC arm discontinued due to urticaria following the W24 visit. Median changes in estimated glomerular filtration (GFRCG) at W48 were -7.0 mL/min for BIC and -11.3 mL/min for DTG with no discontinuations due to renal adverse events. Conclusions: BIC+FTC/TAF and DTG+FTC/TAF both demonstrated high virologic response rates at W24 and W48. Both treatments were well tolerated and no significant safety signal was detected in either arm. Estimated GFRCG changes were consistent with known inhibition of tubular creatinine transport by BIC and DTG. Further evaluation of BIC for the treatment of HIV infection is warranted.

Week 24 a

Week 48 HIV-1 RNA > 50 copies/mL 2 (3.1) 2 (6.1) 1 (1.5) 2 (6.1) Continued.

Week 24 B) Difference in percentages (BIC+FTC/TAF vs DTG+FTC/TAF) at Week 48: 6.4% (-6.0% to 18.8%); p=0.17.

Background: Switching to integrase inhibitor (INI) based ART can reduce toxicities and drug interactions. There is a lack of comparative data between the three current INIs to guide use. Methods: Multicentre retrospective evaluation of patients on ART with HIV VL<50 c/mL switching to a dual-NRTI backbone with the INIs dolutegravir (DTG), cobicistat-boosted elvitegravir (EVG) or raltegravir (RAL) in the UK and Ireland from 1/1/15-31/8/15. The main outcome was 48-week viral suppression (VL<50 c/mL). Missing VL data and INI switches were accounted for in 3 ways: (i) those without a 48-week VL measure excluded (M=E; S=I); (ii) those without a VL measure considered to have VL>50 c/mL (M=F; S=I); (iii) those without a VL measure or who switched from INI considered to have VL>50 c/mL (M=F; S=F; NRTI changes ignored). Reasons for discontinuation and emergent resistance were also summarised. Results: 12 centres provided data on 359 patients. 105 (29%) switched to RAL; 218 (61%) to DTG; and 36 (10%) to EVG. At switch, there were no significant differences in gender (male: RAL-70%, DTG-75%, EVG-72%), median age (46, 47, 48 years), white ethnicity (61%, 65%, 64%) or main HIV risk being sex between men (58%, 61%, 53%). There were differences in percent with CD4<200 cells/ll (0%, 6%, 3%; P=0.03). At 48 weeks, comparable proportions achieved VL<50 c/mL (table, INI switches ignored); however when considering INI switch and missing VL as failure there were significant observed differences (table, M=F; S=F). By 48 weeks, 25/105 (24%) had discontinued RAL, 27/218 (13%) DTG and 8/36 (22%) EVG (P=0.023; 3way comparison). HIV VL was detectable at switch in 2/25 (8%) taking RAL, 2/ 27 (7%) DTG and 0/8 (0%) EVG. No genotypes or resistance development was reported for any patients discontinuing initial INI. Side effects/toxicity was the most common indication for stopping INI (37/60, 62%). Switch for simplification was common for RAL (9/25, 36%). Conclusion: Those switching to INI+2NRTI had high rates of viral suppression, with discontinuations driven mainly by side effects/toxicity. Twice daily dosing of RAL seemed to prompt a small number to switch again for convenience VL<50 Results: 14 centres provided data on 429 patients. 245 (57%) started 2NRTI-RAL; 147 (34%) DTG; and 37 (8%) EVG. At start of ART, there were no significant differences in gender (male: RAL-91%, DTG-90%, EVG-92%), median age (36, 37, 36 years), main HIV risk being sex between men (81%, 74%, 81%), white ethnicity (70%, 74%, 73%), or proportion with CD4<200 cells/ll (17%, 15%, 8%) respectively. At 48 weeks, switch=failure analysis showed a significantly higher percentage with viral response for those on EVG. By 48 weeks 23% (57/245), 6% (9/147) and 5% (2/37) discontinued RAL, DTG and EVG respectively (p<.001 for 3-way comparison). 31/57 (57%) switched from RAL to simplify to a single tablet regimen with VL<50 c/ml. Of those discontinuing initial INI, HIV VL was detectable for 15/57 (26%; 7 switched after 8 weeks) taking RAL, 4/9 (44%; 2 switched after 8 weeks) DTG and 1/2 (50%; 0 switched after 8 weeks) EVG. Genotypes were available for 6/ 15, 2/4 and 0/1 of those who stopped RAL, DTG or EVG respectively with VL>50 c/mL; resistance associated mutations were observed for 2/6 on RAL and 1/2 taking DTG based ART. Conclusion: INI-based ART for treatment na€ ıve patients is associated with high rates of viral suppression. Discontinuation from RAL seems to be driven by patient/doctor choice for once daily ART Background: Due to benefits of antiretroviral treatment (ART) the HIV population is ageing. In the UK one in three people accessing HIV care is now 50 years or over. Dolutegravir (DTG) based regimens (DBRs) have been well tolerated in ART na€ ıve adult studies and have shown superior efficacy versus darunavir/ritonavir (DRV/r) + 2NRTIs (FLAMINGO); the fixed dose combination tenofovir/emtricitabine/efavirenz (SINGLE); atazanavir/ritonavir (ATZ/r) + tenofovir/emtricitabine (TDF/FTC) (ARIA-women only study) and non-inferior efficacy versus raltegravir (RAL) + 2 NRTIs (SPRING-2). This analysis presents the safety and efficacy of DBRs in these phase III/IIIb studies by age group. Methods: Data from the four studies were collated and examined. In SPRING-2 and FLAMINGO investigators were allowed to select NRTIs abacavir/ lamivudine (ABC/3TC) or TDF/FTC, while in SINGLE and ARIA, DTG was used with ABC/3TC versus TDF/FTC with efavirenz (single tablet) and ATV/r respectively. Subjects assigned to DBRs were evaluated by age subgroup; under 50 years or older. Adverse events (AEs), response rates (by FDA Snapshot), co-morbidities and co-medications were summarised in each group.

Results: 1315 subjects were identified; 1157 = <50 (18-49) years vs. 158 = ≥50 (50-85) years. The high efficacy and low AE rates were consistent across both ≥50 and <50 subgroups (Table 1) . Grade 2-4 nervous system (NS) and psychiatric AEs were uncommon. The rate of AEs leading to discontinuation remained low in subjects taking DBRs. Conclusion: Analysis of these studies shows DTG once daily to be an effective and well tolerated treatment option in older patients ≥50 years which is consistent with overall studies result and in the majority patient group <50 years. 

Significant efficacy and long term safety difference with TAF-based STR in naive adults emtricitabine (E/C/F). At Week (W) 48, E/C/F/TAF was statistically noninferior to E/C/F/TDF for the proportion of subjects with HIV-1 RNA <50 copies(c)/mL and had significant improvements in renal and bone safety endpoints. We now describe follow up of blinded data at W144. Methods: ARV na€ ıve participants randomized 1:1 to receive E/C/F/TAF(TAF) or E/C/F/TDF(TDF). W144 viral suppression by FDA snapshot analysis, pre-defined bone and renal safety and tolerability endpoints are reported. Results: 1,733 HIV-infected adults were randomized and treated: 15% women, 43% non-white, 23% viral load >100,000 c/mL. At W144, TAF met prespecified criteria for both noninferiority and superiority to TDF by FDA snapshot algorithm (Table 1) . Mean [SD] % decrease in BMD was significantly less in the TAF group for both lumbar spine and total hip (Table 1) . Multiple measures of renal safety were significantly better for participants randomized to TAF. There were no cases of renal tubulopathy in the TAF arm vs 2 on TDF. No participants on TAF had renal-related discontinuations vs 12 on TDF (p<0.001).

Conclusion: At W144, participants on E/C/F/TAF had significantly higher rate of virologic suppression (<50 c/mL) than those on E/C/F/TDF, driven by fewer participants on E/C/F/TAF with no W144 data. E/C/F/TAF continued to have a statistically superior bone and renal safety profile compared to E/C/F/TDF, demonstrating significant safety advantages over E/C/F/TDF through 3 years of treatment. b-2M/Cr=urine beta-2-microglobulin to creatinine ratio; c/mL=copies/mL; eGFR=estimated glomerular filtration rate; UPCR=urine protein to creatinine ratio; RBP/Cr=urine retinol binding protein to creatinine ratio. We evaluated time from first documented HIV+ test result to date of first ART prescription and virological response. We analysed demographics, HIV viral load (VL), CD4 count, ART regimen, hepatitis B (HBV) and C (HCV) status, recent infection testing algorithm (RITA) test/p24 antigen results, and reasons for non-initiation. We defined lost to follow up (LTFU) as no contact with the unit for >6 months despite >3 attempts to contact via email, text, telephone.

Results: There were 75 eligible patients in the study period, of these 64/75 (85%) were male and median age was 34 (18-84 years) . Of the 59 with CD4 count and HIV VL available, median CD4 count was 465 cells/cc 3 (range 8-1550) and HIV VL was 23326 copies RNA/ml (range 120 ->10000000) at diagnosis. Of the 61 patients with RITA/p24 antigen tests available, 21/61 (34%) were recently infected and 8/21 enrolled into research studies. 2 patients were HBV co-infected and 4 were HCV co-infected. 25 patients (33%) did not start treatment during the study period; 4/25 declined treatment, 6/25 moved to other centres and 15/25 were LTFU. The remaining 50 patients (67%) started ART in the study period. Median time from first HIV+ diagnosis to ART initiation was 31 days (range 10-215). Analysed by quarter, both the proportion of new HIV+ patients initiating ART and the time from first HIV+ test to ART initiation showed no significant change over time. 33/50(66%) commenced an integrase inhibitor based regimen. 29/31(94%) patients with results available at 6-months post ART start had an undetectable VL. Conclusion: In the first year after updated BHIVA guidance publication, we note rapid initiation of ART with excellent virological outcomes for newly diagnosed HIV+ individuals. However, over half of those not starting ART were LTFU, indicating a critical need for novel strategies to improve retention in care.

Successful antiretroviral therapy in a non-urban HIV cohort Method: To be eligible for inclusion into this review an individual had to be under active follow-up and receiving combination antiretroviral therapy for at least 6 months by 31st December 2015 and have CD4 count and HIV viral load data collected during 2015. This was a retrospective review and data was retrieved from clinical case notes and laboratory reports and included data on demographics, current antiretroviral combination, whether the current antiretroviral combination was an individual's first combination or subsequent combination, CD4 cell count and viral load results during the study period. Results: 437 individuals were eligible. 257 (59%) individuals were male and 180 (41%) were female. The median age of the cohort at last review was 46 years (range 19-83 years). 270 (62%) individuals in the cohort acquired their HIV infection via heterosexual contact. 404 (92%) individuals receiving combination antiretroviral therapy for more than 6 months had an undetectable HIV viral load. 281 (64%) were receiving an NNRTI based regimen, 116 (26%) a PI based regimen, and 43 (9%) an integrase based regimen.

Conclusion: Our analysis demonstrates the majority of individuals (92%) receiving antiretroviral therapy in our cohort had an undetectable HIV viral load. This review helps to demonstrate that individuals managed in a smaller non-urban HIV cohort continue to achieve successful treatment outcomes comparable to larger treatment centres and national data.

Background: The impact of switching from EFV/FTC/TDF 600/200/300 mg (GS-US-366-1160) week 4 and week 12 reviews respectively. Of the treatment na€ ıve group (n = 14): 14(100%) were commenced on TAF/FTV/ELV/c due to desire for single tablet regimen. The median VL in this group was 147775 copies/mL at week 0 and 219 copies/mL (BLQ q25 -340 q75 ) at week 4. All patients were fully suppressed by week 12. With regard to renal parameters: median creatinine at week 0 was 87 mmol/L (77 q25 -102 q75 ) and 91 mmol/L (80 q25 -99 q75 ) at week 24. uPCR at week 0 was 12 mg/mmol (9 q25 -17 q75 ) and 13 mg/mmol (9 q25 -18 q75 ) at week 24. 10/119(8.4%) patients reported side effects. These included 3 patients who reported GI symptoms, 2 rash, 1 sleep disturbance, 1 anxiety, 1 palpitations, 1 dizziness and 1 with eye irritation. Side effects led to discontinuation in 1 patient with rash which was directly attributed to TAF. Conclusion: Results indicate that tenofovir alafenamide is well tolerated in our cohort with only 1 discontinuation reported. Virological control is satisfactory in both treatment naive and experienced patients and is comparable to that reported in Phase 3 studies.

The ongoing problem of Cushing's syndrome as a result of drug-drug interactions between steroids and protease inhibitors: a retrospective case series and strategies for avoidance R Simons, S Castelino, A Ali and R Kulasegaram Guy's and St Thomas' NHS Foundation Trust, London, UK Background: Cushing's syndrome and secondary adrenal suppression has been widely reported in HIV positive patients due to the drug-drug interaction between ritonavir boosted protease inhibitors and corticosteroids, however such incidents and resulting harm to patients continues to occur. Method: A retrospective case series was conducted in the HIV cohort of a London teaching hospital and strategies for future avoidance of such incidents considered and put into practice. Results: We report on 10 cases (see table 1 ). Discussion: A co-ordinated, multi-disciplinary approach involving HIV specialist pharmacists is required with collaboration across specialties to avoid these incidents and the resulting harm to patients. Strategies we have implemented include: 1. Presentation at specialty departmental meetings and national conferences 2. Publication of trust guidelines available on intranet 3. Disseminating information via electronic safety bulletins 4. Patient safety cards given to all patients on ritonavir/cobicistat 5. Collaboration with specialties to include a question on antiretroviral therapy on the WHO surgical checklist prior to steroid injection We also aim to include this is in trust induction for all new staff. Clinician-defined slow progression of HIV was a contributing factor to not being on therapy in 15 cases. The median time since HIV diagnosis was 7 years (range 3-13). The CD4 count in these non-progressors was 457 to 1204, and 4 of the 15 had an undetectable viral load. In 5 of these cases, the reasons for not initiating therapy were not clearly documented on HARS. In the remainder, the main reason for not being on therapy was patient preference.

Severe psychological or social problems were a factor in 11 cases, including a comorbid mental health diagnosis (5) and substance misuse (5). Intolerable side effects were a factor in 8 cases. Recent interruptions to care, including transfers of care, were a factor in 10 cases. In 2 cases clinicians deferred ART to allow treatment of opportunistic infections, and in 1 case a patient chose to defer ART due to a recent myocardial infarction.

Conclusion: This single-centre study gives insight on why patients may not initiate ART which is generalizable to other UK centres. The limitations of this study are that it necessarily focuses on patients retained in care, and is limited to note review rather than interviewing patients directly. Slow-progression of HIV is a key factor influencing a decision not to initiate ART within our cohort. Clinicians should ensure they inform patients of benefits and risks of commencing treatment, and document such discussions clearly. When patients transfer care, clinicians should endeavour to provide continuity of care by detailed handover, including the details of such discussions and decisions regarding treatment. Severe psychological or social problems remain an important factor, however the numbers remain small. Background: A small population of cells harbouring an integrated copy of HIV ('the latent reservoir') persist despite effective antiretroviral therapy (ART), and is the barrier to HIV cure. The rarity of these cells and absence of a unique cellsurface marker makes study of this population difficult. Additionally, proviral sequence analysis is complicated by the excess of human genomic material in the reaction. We present a novel HIV DNA capture assay which combined with Next Gen sequencing technology retrieves near full-length HIV sequences as well as integration sites from patient samples. Method: The Agilent SureSelect XT protocol was modified to enrich for HIV proviral DNA. 44,000 unique biotinylated RNA baits homologous to HIV were hybridised to 3 lg CD4 T-cell DNA for 20 hours. Enrichment was achieved by positive selection using streptavidin-coated beads. To improve capture specificity, wash steps were performed at 71°C. Captured DNA was sequenced using the Illumina MiSeq platform and the reads mapped de novo to reconstruct the HIV genome. Integration site analysis was performed in two steps. First, reads were mapped to a HIV reference to profile the LTR. Any reads containing an LTR end motif then had the LTR sequence removed, the remaining human sequence was mapped to the hg19 genome using Novoalign to determine the integration locus.

Results: Near full-length sequence was obtained from mixes of uninfected and infected cell lines and then from 6 HIV infected patients with a range of total HIV DNA as measured by qPCR (1669-13186 copies per million CD4 Tcells). The depth of sequencing coverage achieved for each sample was positively correlated with HIV-DNA (p=0.013). The mean sequencing coverage for patient samples was 69. Consistent with current literature, all primary cell integration sites mapped to intronic regions of the human genome.

Conclusions: We present the first Next Gen-based enrichment protocol which allows near full-length proviral HIV DNA sequence analysis from a broad range of HIV total DNA with integration site identification. The preliminary study of six patients supports the current understanding that a high frequency of deletions are present in the reservoir and that HIV preferentially integrates within intronic regions of highly expressed genes. The combination of a qualitative sequence-based correction of qPCR ("q²PCR") is likely to provide a more accurate reflection of the true reservoir size. Additionally, a comprehensive map of annotated integration sites could also help identify cells most likely to constitute the reservoir. This worked was supported through a BHIVA Research Award to J. Frater

The majority of re-activatable latent HIV proviruses are genetically distinct with no evidence of ongoing evolution HP Mok, N Norton, A Fun, J Hirst, M Wills and A Lever University of Cambridge, UK Background: Two mechanisms have been proposed to contribute to the maintenance of the HIV latent reservoir: homeostatic proliferation of latently infected cells and low level viral replication in the lymphoid tissue. Here we studied the sequences of reactivatable latent viruses obtained from a stably treated patient to assess the importance of these mechanisms.

Methods: Resting CD4+ T cells were isolated at regular intervals from the patient, underwent limiting dilution, were activated and then co-cultured with SupT1-CCR5 cells for 21 days. The supernatant was harvested for viral RNA. Regions in gag and env were analysed by Sanger sequencing. To control for artefacts from culture and sequencing, SupT1-CCR5 cells were infected with NL4-3 and underwent the same limiting dilution, culture, and sequencing processes. Pairwise comparisons were performed to obtain p-distances. Each pair of patient derived viral sequences was considered distinct if the pdistance was higher than that of the corresponding region of the sequences from NL4-3 infected SupT1-CCR5 cells. To seek evidence of viral evolution, a consensus was created from the viral sequences obtained from the first sample and sequences from samples obtained subsequently were compared against this baseline consensus.

We obtained 32 sequences of reactivated latent viruses from a single patient. 18 distinct sequences could be distinguished from the gag region. The remaining 14 sequences segregated into five groups. However, when the env regions of these 14 sequences were analysed, only one 'clonal' group of two sequences remained. 30/32 reactivated latent viruses were distinct. If the threshold p-distance for two sequences to be considered distinct was set at the maximal (rather than average) p-distance observed in the reference set, 26/32 of reactivated latent viruses would still be considered distinct. We have not observed any increase in p-distances over 28 weeks of sampling compared to the baseline samples to suggest of accumulation of mutations. Ever achieving an undetectable viral load was high in both TasP and clinical need groups (100% vs 93% p=0.11). There was a trend towards higher rates of virological failure, as defined by BHIVA, in the clinical group (23% vs 11%) p=0.24. Those starting ART for clinical need were more likely to disengage from care (defined as not attending clinic for 12 months) compared to those starting for TASP (14% vs 0% p=0.05). The number of STIs in the TasP group was higher compared to the clinical group in the 12 months before and 12 months after ART (39% vs 23% p=0.08 and 16% vs 6% p=0.09 respectively). However, there was a fall in the number of STIs in the TasP group in the year following ART compared to the year prior (8% vs 25% p=0.012).

In this cohort patients who started ART for TasP maintained high levels of virological suppression and were less likely to disengage than those starting for clinical need. There was a fall in the incidence of STIs after ART in this group. These findings suggest that concerns about TasP are unfounded.

Real-time partner notification feedback R Betournay 1 , J Paparello 1 and A Menon-Johansson 2 1 Guy's and St Thomas' NHS Foundation Trust, London, UK, 2 SXT Health CIC, London, UK Background: At least a fifth of partners of newly diagnosed HIV positive patients will be infected and for other sexually transmitted infections (STIs) up to two thirds will have an STI. Partner notification (PN) has been shown to be an effective public health strategy and when it is done effectively reduces the cost to diagnose infections. A new tool was developed to support PN delivery and capture patient reported outcomes for STI clinics; however, it had not been tested in an HIV clinic. We therefore introduced the service into an HIV clinic to test its utility to deliver PN and report outcomes. Methods: Analysis was performed following 25 weeks of usage of the PN tool with a focus on the number of index patients, total partners, contactable contacts, the number of partners told and tested either reported by the patient or captured via healthcare worker (HCW) verification using the PN tool. The key performance indicator (KPI) target for STIs has been set as 60 partners seen and tested within four weeks for every 100 index patients (i.e. 0.60), and this was used as a benchmark. Results: PN data was captured for 100 index patients [19 Female all heterosexual (10 Black, 9 White or mixed ethnicity), 58 MSM (49 White or mixed, 5 Asian, 4 Black ethnicity), 16 Heterosexual males (10 Black, 5 White, 1 Asian ethnicity) and nine patients where no demographics were captured] for nine different infections (64 HIV, 21 Syphilis,14 Chlamydia, 11 Gonorrhoea, 5 Hepatitis C, 3 Trichomonas vaginalis, 3 Lymphogranuloma venereum, 1 Hepatitis B, 1 Shigella). Two or more infections were diagnosed in 21 (22%) index patients. There were a total number of 228 partners and 138 (60%) were contactable. Of the contactable contacts 111 (80%) were told and 57 (41%) were seen and tested [19 via PN tool (14 at clinic, 5 reported by the partner), 38 reported by patient]. The shortest time from a partner being told to HCW verification was 78 minutes and the largest distance between the index patient and partner testing clinics was 260 km. The KPI overall since the launch of the tool is 0.57 and at the time of writing it was 0.64 for the last four weeks. Conclusion: The PN tool signed off one third of partners as seen and tested as well as supported the HIV clinic to report its outcomes and achieve the KPI for nine different infections. More work is required to roll out the PN tool, optimize the number of contacts told and support these high public health value partners to be seen and tested.

The effect of binge drinking and recreational drug use on viral non-suppression among people with HIV on antiretroviral treatment in the UK M Kall 1 , A Nardone 1 , V Delpech 1 , J Lewis 2 , L Coyer 2 , M Shahmanesh 3 , R Gilson 3 , H Ward 4 and E Pufall 4 1 Public Health England, London, UK, 2 London School of Hygiene and Tropical Medicine, London, UK, 3 University College London, UK, 4 Imperial College London, UK Background: Viral suppression among people with HIV is vital for individual and public health. Despite excellent quality of care and high rates of viral suppression in the UK, there remains a fraction of people on antiretroviral therapy (ART) that are not virally suppressed. Heavy alcohol use and recreational drug use are known to influence ART adherence, but their downstream effect on viral non-suppression is unclear. We examine the effect of binge drinking and drug use on viral non-suppression in a nationally weighted sample of people accessing HIV care. Methods: Cross-sectional survey data from the Positive Voices pilot (May-November 2014) were linked to clinical data from the 2014 national HIV cohort of persons accessing care. Odds ratios (ORs) for the associations of binge drinking (≥8 drinks for men or ≥6 for women on one occasion at least monthly) and drug use (use of recreational drugs in the past year) with viral non-suppression (≥1 HIV RNA test result ≥50 copies/ml in the past year) were calculated using logistic regression before and after adjusting for self-reported adherence. Analyses were restricted to persons on ART for ≥3 months. Results: Of 611 survey respondents included; 424 (65.7%) were men who have sex with men (MSM), 75 (11.8%) heterosexual men and 112 (17.6%) women. Population-prevalence of binge drinking was 20.9% and drug use 27.8%; with highest prevalence in MSM (33.6% and 54%, respectively). Prevalence of viral non-suppression was 11.6%. Viral non-suppression was higher in binge drinkers compared to non-binge drinkers (15.8% vs 8.9%, p=0.03). After adjusting for drug use, age, HIV risk group and employment status, binge drinkers had double the odds of viral non-suppression compared to non-binge drinkers (aOR=2.22, 95% CI 1.16-4.27, p=0.02). Drug users also had a significantly higher prevalence of viral non-suppression than non-drug users (14.6% vs 8.5%, p=0.015). However after adjustment, no evidence of an association with viral nonsuppression was found (aOR=1.17, 95% CI 0.60-2.28, p=0.64). Adjustment for ART adherence did not change the results. Conclusion: Monthly or more frequent binge drinking is associated with viral non-suppression among those on ART, and this association was not fully explained by the postulated mechanism of ART adherence. Screening for lifestyle behaviours that may impact health including alcohol consumption forms an important part of HIV care. Further research is needed to explore the causal mechanisms. Background: Approximately 1200 pregnancies are reported annually in the United Kingdom (UK) in women diagnosed with HIV. Women living with HIV (WLHIV) may encounter significant psychosocial challenges in their journey to motherhood, even though the UK rate of vertical transmission is currently <0.5%. Peer-support has been shown to have a beneficial impact on the wellbeing of pregnant WLHIV. Building on a London-based 'Mentor Mother' programme, we describe its expansion across the UK and present our preliminary evaluation. Methods: In collaboration with HIV-specific third-sector organisations, we aimed to train 40 WLHIV across the UK as Mentor Mothers (MMs). Our innovative 2-day training package was facilitated by two experienced trainers, one a MM herself. It comprised coaching on clinical and psychosocial aspects of pregnancy and HIV in combination with creative writing workshops to encourage trainees to reflect upon their own pregnancy journeys. Results: Between April and October 2016, the 4M project trained 46 women living with HIV to be MMs, in eight UK regions. The median age of women completing training was 40.5 years (range 22-67); 40% were of Black African ethnicity. Overall feedback from MMs who participated in the project was very positive, with all rating the different components of the training as either good or excellent. Nearly 90% of 'Mentor Mothers' reported that both their knowledge about HIV and pregnancy and confidence in action planning had improved.

A key challenge was achieving the planned number of participants for each workshop; reasons for non-attendance include childcare commitments, and concerns about confidentiality. We reviewed our approach throughout the project in an attempt to mitigate these issues for subsequent sessions. Conclusion: By the end of 2016, we had trained 46 peer Mentor Mothers who were each ready to provide support to at least five other WLHIV. Longer term evaluation is ongoing. This network of Mentor Mothers are an invaluable resource, complementing the clinical care of the management of HIV and pregnancy across the UK.

Adherence and cost saving with the use of Pill Glide in antiretroviral therapy T Busari, N Tickner, S Raghunanan and C Foster Imperial College Healthcare NHS Trust, London, UK Background: Transition from liquid to tablet preparations can be difficult for young children and liquid formulations are expensive and bulky. Additionally, adolescents often struggle with pill swallowing impacting on adherence. Pill Glide â is a lubricating fruit flavoured spray that facilitates tablet swallowing. We audited the pilot use of Pill Glide â in a cohort of perinatally infected children (PaHIV) on antiretroviral therapy (ART). Methods: Retrospective case note and pharmacy dispensing review of PaHIV children under 18 years on ART prescribed Pill Glide â from June-Dec 2016. Data collected included; demographics, ART, adherence, reason for Pill Glide â use and outcomes. Cost saving analysis was performed; Pill Glide â costed at £5.90 per bottle for 200 doses, recommended 2-4 sprays per pill. Results: 7 children, 86% female, 57% black African, median age 10 (range 6-16) years received Pill Glide â all with successful transition to tablets/improved adherence/tolerability. In patients switching from liquids to tablets, average annual cost saving was £182 per patient. Predicted to rise to £1003 with a switch from Kivexa â to generic abacavir/lamivudine in 2017.

Conclusion: Pill Glide â assisted in the transition from liquids to tablets in this small cohort, with cost saving. Further exploration in nonadherent adolescents reporting swallowing difficulties is warranted. Subsequently, Pill Glide â is being used in paediatric TB, rheumatology and bone marrow transplant services within the trust. 

Complexities of establishing antiretroviral therapy in a female of childbearing age with subsequent successful use of maraviroc in pregnancy E McCarty and S Todd Royal Victoria Hospital, Belfast, UK Background: Significant advances in antiretroviral therapy (ART) such as new drug classes, greater choice of drugs in-class and new treatment combinations/single tablet regimes have meant that it is less common in clinical practice to experience difficulty constructing a suitable regime, particularly in the absence of drug resistance or complex comorbidities. We present a case outlining the complexity of treating a 30 year female with significant side effects/toxicities across a number of ARV classes who subsequently became pregnant. Case Report: 30 year old Caucasian female diagnosed with HIV-1 infection following routine GUM screen in 2012. Nadir CD4 count 250 9 10 6 /L (33%) and HIV-1 RNA viral load at diagnosis 28,586 copies/mL. Resistance profile showed wild type virus with no major mutations. HLA-B5701 was negative. Patient had history of depression and ongoing issues with bulimia. She struggled with diagnosis and significant input was required by psychology before she agreed in April 2014 to commence treatment with TDF/FTC/DRV/r. Within 7 days she developed widespread erythrodermic rash necessitating hospital admission. ARVs were stopped and she was treated with oral steroids and antihistamines. Reluctantly she agreed to re-commence ARV's with ABC/ 3TC/Dolutegravir in July 2014. Three months later she presented with generalised anxiety disorder and reported difficulty coping with everyday tasks and social withdrawal. These symptoms were attributed to dolutegravir and settled soon after switching to ABC/3TC/ATZ/r. At review 1 week later, she had widespread maculopapular rash and hyperbilirubinaemia (bilirubin 100 lmol/ L). ATZ/r was switched to raltegravir alongside ABC/3TC backbone. Within 4 weeks she reported palpitations, panic attacks and anxiety. Alternative agents were excluded-rilpivirine was unsuitable due to food requirement in context of bulimia and etravirine associated with 10% risk rash. She was CCR5 tropic and was prescribed maraviroc 300 mg BD with ABC/3TC. This was well tolerated with no side effects. One year later she presented to clinic 11 weeks pregnant. She opted to stay on maraviroc despite limited safety data in pregnancy and went on to deliver healthy baby boy at full-term. Conclusion: Even in the context of a wide choice of available ARV regimes, complexities can still arise constructing an effective, well-tolerated regime especially in context of pregnancy where limited safety data exists for newer drugs.

Complicated triplet pregnancy in a poorly compliant HIVpositive woman: a case report SM Afzal and N Bodasing University Hospital North Midlands, Stoke-on-Trent, UK Introduction: The rate of HIV mother-to-child-transmission in the UK has improved dramatically from 25.6% in 2003 to 0.57% in 2011, due to a combination of successful maternal antiretroviral (ARV) therapy, planned delivery and formula-feeding. Unfortunately, chaotic lifestyles may prevent women from adhering to therapy, increasing risk of vertical transmission. To date, there are few documented cases of successful seronegative multiple pregnancies in poorly compliant HIV-positive women. We present a case of trizygotic triplet pregnancy in a poorly-compliant HIV-positive patient. Case report: X, a 32-year old HIV positive woman with known poor ARV adherence, variable engagement with services and recent admission with pneumocystis jiroveci pneumonia presented to clinic four weeks pregnant. At this point, she was a single mother with two children (including one child with special needs), a university student and a part-time employee. She had poorly controlled HIV (CD4 72 cells/ll, VL 272528 copies/ml) but was keen to reengage with services. X resumed her once daily regime of Truvada and boosted Darunavir but had difficulty with treatment adherence and engagement, partly due to confidentiality concerns. With multi-disciplinary team support (including community volunteer input), treatment was intensified to twice daily boosted darunavir with addition of raltegravir, but her viral load remained detectable (above 200 copies/ml). Her pregnancy was complicated by loss of one triplet in the first trimester, one admission with possible spontaneous rupture of membranes (SROM) at 33 weeks, and breech presentation of both twins (although twin B performed spontaneous cephalic version). X improved adherence closer to delivery and viral load at 36 weeks gestation was 63 copies/ml. She delivered two healthy babies via elective caesarean section at 37 weeks gestation. Both twins had negative HIV DNA PCR levels at birth, 6 weeks and 12 weeks of age. The twins received zidovudine prophylaxis for four weeks and are currently developing well on formula feed. Conclusion: This case highlights the importance of a multi-disciplinary team approach in managing adherence, contraception, confidentiality, psychosocial, obstetric and paediatric challenges in multiple pregnancies amongst poorly adherent HIV-positive women. HIV clinics should improve collaborations with the community voluntary sector to optimise patient care.

Dolutegravir in pregnancy: a retrospective case review R Simons and R Kulasegaram Guy's and St Thomas' NHS Foundation Trust, London, UK Background: Data on dolutegravir use in pregnancy are limited and the manufacturer advises avoiding exposure unless risks outweigh benefits. BHIVA guidelines suggest that more established options should ideally be used. Methods: A retrospective case review of all HIV-1 positive pregnant women prescribed dolutegravir or Triumeq â (abacavir/lamivudine/dolutegravir) was conducted between April 2015 and January 2017 in a London teaching hospital. Demographics, data on efficacy, tolerability and maternal and infant outcomes were collected. Results: 16 pregnant women were prescribed dolutegravir. (13 women have delivered to date; the 3 remaining pregnancies are in the third trimester). Outcomes for 7 of these women were presented at BHIVA 2016. Median age was 29 (range 18-41). 88% (14/16) were of Black-African ethnicity. 15 women were prescribed Triumeq â and one dolutegravir in combination with Truvada, Darunavir and Ritonavir. 2 women conceived on dolutegravir, the remaining women were started or switched at a median gestational age of 16 weeks (range 8-32 weeks). Reasons for use included previous poor adherence, need for rapid virological suppression and gastrointestinal side effects with other regimens. Median baseline HIV viral load was 3918 copies/ml (range 19-64364). All 16 (100%) women achieved full virological suppression. Median time to suppression was 28 days (range 13-62). All 13 women who have delivered to date had an HIV viral load <20 copies/ml at delivery and the remaining 3 women had a viral load <100 when last measured. Dolutegravir was well tolerated with no discontinuations. 54% (7/13) had vaginal deliveries, 2 (15%) planned caesarean sections and the remaining 4 emergency caesarean sections for obstetric reasons. Median gestational age at delivery was 39 + 4 weeks (range 28 + 2-41 + 5). There was one pre-term delivery at 28 + 2 weeks; this patient had an emergency caesarean for foetal distress with uncontrolled maternal hypertension which pre-existed her pregnancy. Median birth-weight was 3300 g (range 810-4025 g). There were no foetal abnormalities noted. 100% (12/12) of babies born in the UK were HIV DNA PCR negative.

Conclusion: This small case series suggests that the use of dolutegravir in pregnancy is effective, well tolerated and appears safe. However additional data from cohort studies, clinical trials and the antiretroviral pregnancy registry are required.

Four year follow-up of HIV infected children and adolescents requiring measles, rubella and chickenpox vaccination 

HIV-1-positive pregnancies demonstrate altered IFNc and IL-10 responses to flu and CMV and disrupted DC, NK and Tcell profiles A Cocker 1 , N Imami 1 , M Johnson 1 , S Dermont 2 and W Khan 2 1 Imperial College London, UK, 2 Chelsea and Westminster Hospital, London, UK Background: Pregnancy induces alterations in immune cell function and phenotype to support the developing fetus while protecting against pathogens. HIV-1 disrupts immune function, is associated with higher rates of viral co-infection, and increased incidence of pregnancy complications. This study aims to investigate the impact of HIV-1 on antiviral responses and peripheral blood mononuclear cell (PBMC) profiles during pregnancy. Methods: HIV-1 À non-pregnant (n=22), pregnant (n=21) and HIV-1 + pregnant women on antiretroviral therapy (ART) (n=11) were recruited, their PBMC isolated, and IFNc and IL-10 ELISpot assays performed. Gag and Nef responses were tested in HIV-1 + individuals only. Flow cytometric analysis of PBMC was undertaken to determine the expression of activation, differentiation and exhaustion markers of dendritic cells (DC), natural killer cells (NK) and T cells. Statistical analysis was carried out using Prism version 7.0. Intergroup variation was assessed by Mann-Whitney tests and statistical significance defined as p = <0.05. Results: There was an increase in HIV-1 + pregnant IFNc response compared to both HIV-1 À non-pregnant and pregnant groups against Flu (p=0.0607 and p=0.0148 respectively), and CMV (p=0.0176, p=0.0219). IL-10 response was lower in the HIV-1 À pregnant group than non-pregnant against Flu and CMV (p=0.0015, p=0.0440); the HIV-1 + group showed reduced IL-10 responses compared to the pregnant group to both antigens (p=0.0704, p=0.0198). Eighty per cent (8/10) of HIV-1 + women were IFNc responders to Gag, and 70% (7/10) were Nef responders. Phenotypic comparison of pregnant groups showed increased frequency of exhausted (PD-1 + ) CD4 and CD8 T cells in HIV-1 + women (p=0.0048, p=0.0346), reduced anergic NK CD56 À CD16 + CD11b + CD27 À and CD56 À CD16 + NKp30 + NKG2A + populations (p=0.0247, p=0.0064), and raised plasmacytoid DC to myeloid DC 1 and 2 ratio (p=0.0159). Conclusion: Despite ART HIV-1 persists, as shown by Gag and Nef responses. Group differences observed reflect prolonged immune activation and disrupted functional regulation. Furthermore, similar PBMC profiles have been previously associated with HIV-1 À pregnancy complications. These findings demonstrate the impact of viral persistence on innate and acquired immunity, implicating HIV-1 as a confounding factor for complications in treated pregnancies, and warranting more in depth functional analysis in this cohort.

Maternal carriage of Group B streptococcus in HIV-positive women, and subsequent neonatal infection M Watts 1 , A Dempsey 2 , K MacLeod 2 and D Kirkham 3 1 University of Manchester, UK, 2 St Mary's Hospital, Manchester, UK, 3 Manchester Royal Infirmary, UK Background: Group B streptococcus (GBS) is the leading cause of neonatal sepsis. Early onset GBS disease occurs within 7 days of age and is linked to intrapartum GBS exposure. Nationally, early onset GBS disease occurs in 2.3/ 1000 neonates, with GBS carriage rates in pregnancy of 21%. Infection after 7 days of age (late onset disease) is not thought to be related to intrapartum transmission. Unlike the USA and Canada, there is no UK GBS screening programme. Studies suggest increased GBS carriage in HIV-infected women and increased GBS disease in HIV-exposed uninfected neonates. The audit assessed GBS carriage in HIV-infected women and GBS disease in HIV-exposed uninfected neonates to guide antenatal management. Methods: Retrospective audit of 254 HIV-infected pregnant women delivering at St Mary's Hospital, Manchester (March 2008 -November 2015 . Maternal information was reviewed including GBS carriage on high vaginal swab or mid-stream urine samples, and intrapartum antibiotic prophylaxis. Neonatal records were reviewed for GBS status including CSF and blood cultures. Results: 37 women (15%) had HIV diagnosed in pregnancy. 147 women (58%) were on treatment prior to conception. 100 women (39%) were tested for GBS in pregnancy with a carriage rate of 16% on high vaginal swab. Women diagnosed with HIV in pregnancy did not have higher GBS carriage. There was no difference in baseline viral load or CD4 count in pregnancy between the whole cohort and those carrying GBS. There was also no observed reduction in GBS carriage in those on anti-retrovirals prior to conception. Intrapartum antibiotic prophylaxis was used appropriately in all cases. No baby tested positive for GBS in either early or late onset disease investigations (40 blood cultures and 4 CSF cultures <7 days, and 9 blood cultures and 2 CSF cultures >7 days). Conclusion: The cohort GBS carriage rate was 17% which is comparable to national figures. Viral load, CD4, and being on treatment prior to conception did not affect GBS carriage rates. There were no cases of early or late onset GBS disease. This supports the current UK practice of no routine screening for GBS carriage, and contradicts studies suggesting increased GBS carriage in HIV-infected women and increased GBS disease in HIV-exposed uninfected neonates.

Predicting future cardiovascular risk in adolescents with perinatally acquired HIV R Karunaratne and C Foster Imperial College Healthcare NHS Trust, London, UK Background: Early data suggests that perinatally HIV-infected (PaHIV) young people may have an increased risk of cardiovascular (CVS) disease in adulthood, attributed to both the prolonged exposure to HIV and antiretroviral therapy (ART). Whilst CVS risk algorithms are commonly used in adults, comparable tools for young people are less developed. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) coronary arteries (CA) and abdominal aorta (AA) risk scores are a weighted aggregate of modifiable risk factors: dyslipidaemia, cigarette smoking, hypertension, obesity, and hyperglycaemia, and have been validated in US adolescent populations but with minimal data in PaHIV cohorts. Methods: PDAY scores were calculated for adolescents aged 15-19 years on ART using retrospective observational cohort data from electronic records between November 2015 and January 2017. PDAY score >1 is strongly associated with the presence and intensity of subclinical coronary and abdominal atherosclerosis at autopsy 25 years later. A baseline PDAY risk score of ≥2 in adolescence is associated with an increased risk of atherosclerosis in middle age. Results: Of 42 PaHIV adolescents; median age 17 years (IQR 16-18), 60% were female, 66% black African, median CD4 count 716 cells/ll (IQR 528-954) and 86% had a viral load <50 c/ml. 7% had a BMI >30, 26% were hypertensive (>95 th centile for age/height) and 14% were current smokers. 14% had a total cholesterol >5 mmols/L, median HDL was 1.3 mmol/l (IQR 1.1-1.6) with a median non HDL of 2.8 mmol/l (IQR 2.3-3.1). 81% and 45% had AA and CA PDAY scores ≥ 1, 48% and 43% had AA and CA PDAY scores ≥2 and 26% and 12% had AA and CA PDAY scores ≥5 with the highest CA score of 10. The mean AA score was 2.5 (95% CI 1.8-3.1) with a median of 1 and a mean CA score of 1.4 (95% CI 0.5-2.2) with median CA of 0. Conclusion: PDAY scores in this cohort suggest a considerable increase in the burden of atherosclerotic cardiovascular risk factors in UK PaHIV adolescents and were twice that of US PaHIV populations. PDAY scores may be valuable in identifying individuals at highest risk of developing atherosclerotic lesions, for whom therapies may be targeted and management modified to reduce their risk factor burden and risk of cardiovascular disease in later adulthood.

Referral to Community Adolescent Mental Health Services (CAMHS) in a perinatally infected adolescent cohort P Seery, A Freeman and C Foster Imperial NHS Healthcare Trust, London, UK Background: Early data suggests an increase in mental health diagnoses in both perinatally infected adolescents and their uninfected siblings when compared to their peers. This study aims to characterise the different mental health (MH) presentations in the paediatric setting and elucidate the clinical and psychosocial features seen. Methods: A retrospective case note audit of all referrals to mental health services of adolescents aged between 13 and 17 years between 2012 and 2016.

Results: 17 adolescents were referred to mental health services at a median age of 17 years (IQR 15-17) of whom 82% were female, 100% black African ethnicity, 35% with known learning disabilities (LD), 10 (59%) had experienced parental separation due to death (5), divorce (3) and migration (2). Ten (59%) were known to social services of whom 2 were looked after children (LAC). Annual incidence of new mental health referrals within the adolescents cohort (13-17 years); mean 4.8%, range 0-11.8%, highest in 2016. Primary reason for CAMHS referral: psychosis (3), suicide (1), autism with conduct disorder (1), mood disorder (12) (76%) consisting: depression (7), anxiety (2), mixed (3) with five having a history of self-harm. At referral 14 (82%) had VL <20 copies/ml, with a median CD4 count 568 cells/lL (IQR 356-729). 5 required acute admission (table 1 Admissions); 4 under MHA section; 2 to psychiatric services and 3 to paediatric wards, the latter all with first psychotic episode requiring assessment for organic causes. Only three of 12 (25%) outpatients ever engaged with CAMHS, and the remainder received psychology support in the paediatric HIV service.

Conclusion: Despite good virological control, new mental health presentations peaked at 17 years with multiple known risk factors and poor subsequent engagement with CAMHS. Carefully planned transition to adult services is required for this highly vulnerable complex population.

Testing children of HIV-positive parents: don't forget the fathers I Cormack Croydon University Hospital, UK Background: 'Don't forget the children' (2009) stated ' 'The HIV status of all the children of known HIV-positive adults in the UK should be known as a matter of clinical urgency' Methods: Analysis of all HIV positive mothers and fathers seen at an HIV outpatient clinic by their consultant was carried out during 2016. This HIV cohort is predominantly black-african and 51% are female. All existing case notes were reviewed and confirmation of children's details and HIV status verified from IT systems and other notes where possible. Results: Mothers: 264 children were born to 107 HIV positive mothers.120 are adults (33 of whom were reported as being HIV negative) with 144 children still under the age of 18 years in 2016. 24 children did not need testing as their mother was verified HIV negative after their birthdate. 107 children were verified as HIV negative, 10 were verified as HIV positive. 117/120(97%) verified as tested. 2 were still under active health advisor (HA) follow-up and 1 was reported as negative but living abroad. Fathers: There were 187 children of 68 HIV positive fathers. 61 are adults. 72 children did not need testing as their mothers were verified HIV negative after their birthdate. 38 children were verified as HIV negative, 2 verified as HIV positive. 40/54 (74%) verified as tested. 1 child has been referred for testing by provider referral. 7 children were reported as negative but could not be confirmed as they are living abroad. 6 children were reported as not being in contact with their fathers. Overall: There were 175 HIV positive parents with 270 children under the age of 18 years. 157/174(90%) children that required testing were verified as tested (12/174(7%) verified positive), 3 are under active follow-up of testing, 8 are reported as negative but living abroad and 6 children are reported as having no contact with their fathers. Conclusion: The overall rate of verified testing of children was high (90%) but testing and tracing the children of HIV positive fathers was more challenging and the rate of verified testing was much lower (74%).

The utility of antiretroviral drug levels and the effects on HIV viral load and clinical outcomes in pregnancy N Astill, N Ekong, A Simonini, S Schoeman and J Wilson Leeds Teaching Hospitals Trust, UK Background: BHIVA pregnancy guidelines consider, but do not recommend, therapeutic drug monitoring (TDM) for patients on protease inhibitors (PIs), particularly if combining tenofovir and atazanavir. Data on the pharmacokinetics of antiretrovirals (ARVs) in pregnancy is scanty and the evidence for TDM improving outcomes is conflicting. We therefore evaluated TDM results in pregnancy to assess their utility. Aims: To identify the rate of sub-therapeutic drug levels and any associated factors. To assess the effect on viral load (VL) and clinical outcomes. Method: Retrospective case-note review of all TDM performed from 01/01/ 2012 to 31/12/2015 in pregnant women. Results: TDM was performed in 47 out of 150 pregnancies over the 4 years. Median gestation of TDM was 28 weeks (range 23-34 weeks). 92% were diagnosed with HIV pre-pregnancy, 69% conceived on ART, 62% had baseline VL <20. 23% (11) had sub-therapeutic drug levels. All were diagnosed with HIV prepregnancy and 7/11 conceived on ART. 47% (22) on atazanavir, 37% (8/22) were sub-therapeutic 32% (15) on atazanavir and tenofovir, 40% (6/15) were sub-therapeutic 15% (7) on atazanavir but not tenofovir, 29% (2/7) were sub-therapeutic 28% (13) on darunavir; 15% (2/13) were sub-therapeutic 19% (9) on neviripine MR; 11% (1/11) was sub-therapeutic ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70

Comparing sub-therapeutic drug levels on atazanavir versus other third agents p=0.08. No other factors were associated with sub-therapeutic drug levels. 8/11 had ART dose change made and 1 had a formulation change to aid compliance. 1 had TDM performed near the start of treatment so repeat was arranged. 1 was a poor attender so no adjustments were possible before delivery. The effects of the TDM levels on VL and clinical outcomes are shown in table 1. Conclusion: High rates of sub-therapeutic drug levels were identified with atazanavir particularly when combined with tenofovir. There was no association between sub-therapeutic levels and detectable VL at TDM, at 36/40 or with clinical outcomes. However ART adjustments had been made in most with sub-therapeutic levels. As alternatives are available we no longer initiate atazanvir/tenofovir containing regimens in pregnancy.

P Olupot-Olupot 1 , S Nsubuga 2 and J Meadway 3 1 Mbale Regional Referral Hospital, Uganda, 2 Busitema University, Mbale, Uganda, 3 Medicines for Muheza, London, UK Background: Early Infant Diagnosis (EID) of HIV in exposed infants aims to provide the earliest opportunity for diagnosis, tracking elimination of mother to child transmission of HIV (eMTCT) and subsequent enrolment of infants found PCR-positive into available antiretroviral therapy (ART). The implementation of Ugandan National HIV Prevention Strategies includes EID. We assessed the trends in EID in Eastren Uganda before and after the NHPS.

Methods: This was a 6-year (2011-2016) study on EID incorporating both retrospective quantitative and prospective qualitative studies. Qualitative studies were done through focus group discussions (FGD) and Key informant interviews (KII) at inception (November 2011) and after the implementation (June 2016) of NHPS. Qualitative data were captured on source documents, written narratives and voice recorders. Retrospective data was abstracted from the EID registers for the year 2010 and 2015 corresponding to before and the end of NHPS respectively. Ethical permission to conduct this study was obtained. Results: There was high level of knowledge and support from the policy makers and healthcare providers before and after the implementation of NHPS. Health workers supported modified breast-feeding, HAART for the mother and newborn. Knowledge on EID among pregnant and postnatal mothers was low in the beginning but markedly increased at the end of NHPS period. In 2010, there were 9/69(13.0%) and in 2015 14/336(4.2%) newborn HIV infections respectively. Conclusion: The marked support for NHPS from policy makers and healthcare providers right from the beginning and through its implementation, together with increase in knowledge of EID among mothers attending antenatal care could have contributed to the marked fall in MTCT during the period. , which progressed to require haemodialysis in May 2016, non-epileptiform attack disorder, depression, asthma and recently treated syphilis. In September 2016 he was admitted from dialysis after becoming unresponsive and hypertensive (220/150 mmHg); he suffered a single self-terminating seizure. CT head showed deep white matter hypodensities but no haemorrhage or infarct. Blood pressure (BP) was extremely labile, GTN and labetalol infusions were commenced but on-going seizure activity warranted intubation. MRI brain showed extensive ischaemic changes within the cerebral and cerebellar hemispheres: consistent with PRES and watershed infarcts. Lumbar puncture: opening pressure 33 cm H 2 O, protein 1162 mg/L, glucose 4.2 mmol/L, WBC and RBC <1, microscopy and culture, virology and syphilis serology negative. He had a prolonged period of ventilation; BP control remained difficult, he received methylprednisolone and IV immunoglobulin to cover vasculitis as a differential diagnosis; although imaging and serology did not suggest this. A hypertension screen was negative and syphilis serology confirmed response to recent treatment. Eventually his clinical condition improved and he returned to the ward. Despite 4 oral antihypertensive agents episodes of hypertension >200/120 mmHg resulted in sudden cortical blindness with increased T2 signal within the right medial, parietal and occipital lobes on MRI: again consistent with PRES. Up-titration of oral antihypertensives with regular ultrafiltration and fluid restriction facilitated BP control and, in correlation with the natural history of PRES, his vision completely returned. He was discharged after 69 days. Conclusion: PRES is a rare condition of which the aetiology remains unclear and is infrequently reported in HIV, with fewer than 15 cases reported over the last 20 years. Hypertension is one of the most well documented causes for which treatment includes maintenance of normotension, as demonstrated in this case.

A case of tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS) managed with an interleukin-1 receptor antagonist

Background: Treatment of co-infection with Mycobacterium tuberculosis (TB) and HIV is a relatively common phenomenon within an infectious diseases setting. Within this cohort of patients, there is an increased risk of IRIS upon initiation of highly active antiretroviral therapy (HAART). However in cases where steroids are either not effective or have to be used for long periods the treatment options are less clear but may include immune modulating therapies.

Case Study: A 33-year-old Ethiopian female patient, presented with fever, night sweats and weight loss with associated wide spread lymphadenopathy. At the time of presentation she had been living in the UK for a year with no reported medical problems. She was diagnosed with HIV and disseminated TB with baseline CD4 count of 60. During her initial presentation, her condition worsened and MRI brain imaging showed widespread lesions, with cerebral TB confirmed by cerebrospinal fluid examination. The patient was commenced on antiretrovirals and anti-tuberculosis treatment to which she initially responded well. She then developed IRIS with massive cervical and intraabdominal lymphadenopathy. The IRIS was responsive to steroids, however due to ongoing inflammatory response she required a protracted course. The ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 patient subsequently developed secondary renal amyloidosis as a result of the underlying inflammatory process. The patient received 12 months of anti-TB therapy to good effect. After onset of IRIS, steroids were used to reduce inflammation and control renal amyloid to good effect. Unfortunately steroids were unable to be weaned due to recurrence of symptoms associated with IRIS and also due to steroid-associated side effects. Montelukast was used to try to attempt suppression of IRIS, but to very limited effect. The IRIS itself was an unusual manifestation due to the protracted length, lasting around 5 years. Anakinra, an interleukin-1 receptor antagonist was subsequently used to switch off the pro-inflammatory process. The patient's viral load was eventually undetectable 6 years after first diagnosis despite good compliance with medication due to several resistance mutations. Conclusion: IRIS can be a difficult to manage in the context of a patient with complex morbidity as a result of HIV infection. The case described here highlights the use of immune therapies in the management of IRIS in order to control the inflammatory process and avoidance of long-term steroids.

A review of renal histology in HIV-1 infected individuals on tenofovir disoproxil fumarate (TDF), could there be glomerular involvement?

M Cevik 1 , C Leen 1 and D Raha 2 1 Western General Hospital, Edinburgh, UK, 2 Chalmers Sexual Health Centre, Edinburgh, UK Background: Although the deterioration of renal function is multifactorial, according to our knowledge, patients receiving a TDF containing regimen have an increased risk of renal impairment. It's a particular concern as TDF especially is now more widely used for PrEP and PEP. There is data to suggest that TDF targets proximal tubular mitochondria, however, the exact mechanism of TDF nephrotoxicity is still not clear. Histopathologically, it is characterized by proximal renal tubular injury and dysmorphic mitochondria. We present an analysis of renal biopsies in individuals receiving TDF containing regimens with an aim of improving our understanding of nephrotoxicity in HIV. Methods: We identified all HIV-1 infected individuals who had renal biopsy performed over the past 10 years at the Western General Hospital. We included those individuals who were on TDF containing regimen at the time of renal biopsy. Data were retrospectively collated through electronic patient records and pathology records. Descriptive statistics were performed. Results: Of the 23 individuals who had renal biopsy, we included 10 (3 female) who were on TDF containing regimen. Median age was 48 years (41-57) and 6 were diagnosed with HIV in pre-ART era. 7 individuals had renal biopsy due to renal impairment and proteinuria, 3 individuals had it due to proteinuria only. 60% individuals had biopsy-proven TDF nephrotoxicity also had interstitial nephritis, 20% had mild mesangioproliferative glomerulonephritis, 10% had HIV-associated immune complex glomerulonephritis and 10% had lupus like glomerulonephritis. Of the 6 individuals with TDF related toxicity, 4 individuals had both proteinuria and haematuria at the time of renal biopsy. Histopathology of those with TDF related toxicity was consistent with tubular injury and 2 had eosinophilic inclusions which were positive on trichome stain. 2 of those had tubular mitochondrial injury confirmed by electron microscopy (EM), 4 had nondiagnostic EM. All except one had complete resolution of proteinuria and renal impairment after discontinuation of TDF. One individual required haemodialysis which eventually resolved and one individual has CKD. Conclusion: Although TDF toxicity is described as tubular injury, in our cohort 4 out of 6 individuals also had haematuria which then resolved after discontinuation of TDF. Haematuria would be in consistent with glomerular injury however this was not previously reported in TDF related renal toxicity.

A review of the introduction of an acute kidney injury (AKI) alert into HIV care A Picken, D Williams and E Kingdon Brighton and Sussex University Hospitals, Brighton, UK Background: Human immunodeficiency virus (HIV) leaves patients at risk of both acute kidney injury (AKI) and chronic kidney disease (CKD), with a bidirectional relationship.

In western settings, the kidney problems in this population are more heavily attributed to medication nephrotoxicities than to HIV-related kidney disease. Co-infection with Hepatitis B and C, low CD4 counts and high viral loads can contribute to a patient's risk of renal disease. AKI susceptibility increases with age, and with co-morbid co-infection, hypertension, diabetes and cardiovascular disease. Up to 20% of acute hospital admissions will have AKI. Prompt identification of AKI is likely to favourably influence short-term outcomes and sequelae. Objectives: We sought to investigate the epidemiology of AKI in a centre with a tertiary HIV practice and a regional renal unit. To describe the population of HIV+ve patients developing AKI since the introduction of the ICE pathology AKI alert system. Methods: This was a retrospective analysis of AKI in a centre serving 2400 patients with HIV in a large teaching hospital. AKI cases were ascertained by 3 means a) the national AKI detection algorithm run in local middleware software (ICE-Sunquest) b) Review of all coding data searching for cases with an AKI code (N179) and a consultant caring for HIV+ve in-patients and c) an Excel database of HIV+ve in-patients. Data was collected between December 2015 and Nov 2016. Medical notes were reviewed to cross-reference for clinical diagnoses of AKI. Conclusion: AKI is an unusual event in our experience. The different methods of identifying AKI episodes had limited overlap. The national AKI algorithm requires comparison of old and current results. It is possible that storage of results under different identities has led to an underestimate of the prevalence of AKI. Further work is underway to identify causes of AKI and outcomes in this cohort. The Venn diagram illustrates the distribution of where cases of patients with AKI were identified from in this retrospective study.

A review of thrombotic disease in the HAART era D Friday, H Coleman, G Brook, M Kapembwa and S Murphy London Northwest Healthcare NHS Trust, UK Background: HIV infection is a recognised pro-thrombotic state. The prevalence of venous thromboembolisms (VTE) among HIV infected patients range from 0.19% to 7.63% per year. There is a two to tenfold increased risk of venous thrombosis in comparison with a general population of the same age. Many aspects of VTE and HIV infection have described in detail in the literature. However, there has been little information on hepatic vein thrombosis (HVT) in the HIV infected population. The objectives of this case series are 1. Review the proportion of people with VTE who had HVT in our cohort. 2. Emphasize the need for prevention and 3. Recognize the need for vigorous treatment of this complication. Method: A retrospective review of HIV positive patients diagnosed with thrombotic disease in the last 6 years was conducted. Analysis included demographic data, associated co-morbidities, risk factors for thrombotic disease, anti-retroviral therapy, CD4 count and viral load. Results: In a cohort of 1000 patients 12 had thrombotic disease in the study period of 6 years. 7 females (58%) and 5 (42%) males, age 36-76 years. 50% had a nadir CD4 count less than 200 but at the time of the thrombotic event the CD4 counts were all greater than 200 with undetectable viral loads. 9 (75%) patients had a diagnosis of HIV for more than 10 years. 11 (92%) patients apart were on anti-retrovirals (ARVs) prior to a VTE for at least 6 years. 5 (42%) patients were on a protease (PI) based regimen and 7 (58%) non-PI based regimens. In 5 (42%) cases there were no risk factors for VTE. In the other 7 (58%) risk factors included recent surgery, antiphospholipid syndrome, combined oral contraception use, immobility, liver abscess and nephrotic syndrome. The types of VTE included hepatic vein thrombosis 5 (42%), 2 (16%) deep vein thrombosis (DVT) and 5 (42%) combined DVTs and pulmonary embolisms (PE). All patients were commenced on warfarin. Those without risk factors were investigated thoroughly and no underlying cause found. 11 (92%) patients were found to have multiple co-morbidities. Conclusion: The prevalence of thrombotic disease in our HIV cohort was 1.2% over a 6 year period, with HVT seen frequently at 42% compared to DVTs or PEs. Patients who developed HVT were virologically suppressed with no apparent predisposing factors and had prolonged PI use. Physicians caring for HIV positive patients should be able to recognise and treat VTE as complications of treated chronic HIV infection.

An audit of the care and monitoring of patients co-infected with HIV and hepatitis C in GUM in Edinburgh: need for better documentation identified H Pollitt and D Raha Chalmers Centre, Edinburgh, UK

Background: Hepatitis C co-infection in HIV patients increases the risk of liver cirrhosis and hepatocellular carcinoma (HCC). Hence it is important that co-infected patients are screened and monitored appropriately. We present an audit for this from the GUM department in Edinburgh. Methods: We used the BHIVA guidelines on management of HIV and Hepatitis C co-infection to formulate our data fields; aiming to audit how well we are complying with these guidelines. We used the information from the 4 different IT systems used locally and paper notes. We looked back over the last 5 years of documentation. Our data fields include; age, gender, date of HCV diagnosis, date of HIV diagnosis, is the GP aware of HIV and HCV diagnosis, mode of transmission, latest CD4 count, current ARV regimen, date ARV started, CD4 when ARV started, was HCV diagnosed when ARV started, has HCV been treated, type and length of treatment, why treatment was stopped, if acute HCV was treatment started within 6-12 months, has there been speciality input, referral to drug and alcohol services, referral to mental health, HEV screening, HAV serology and vaccine, HBV serology and vaccine, fibroscan, LFTs, liver biopsy, has risk reduction been discussed, if cirrhotic when was their last liver ultrasound and AFP, have they had an endoscopy, have they been referred for liver transplant, if they have had no HCV treatment do they have an annual fibrosis assessment. Results: Number of patients identified to be co-infected with HIV and HCV under the care of GUM=16 Non-treated patients (10) Annual fibrosis assessment 0/10 Conclusion: In our HIV patients documentation of Hepatitis C care is spread over 4 different IT systems and paper notes. The collation of data to ensure each patient is receiving appropriate care and monitoring is therefore timeconsuming and unwieldy. The results of this audit shows there needs to be a more cohesive way of documenting results and plans for these patients to ensure safe clinical care and effective handover to other clinicians. This will be addressed and the aim is to introduce a better system of documentation as a result of this audit.

An unusual cause of isolated secondary ovarian failure due to cerebral toxoplasmosis in an African woman with AIDS K Yoganathan 1 , S Sadiq 2 and K Yoganathan 1 1 Singleton Hospital, Swansea, UK, 2 Morriston Hospital, Swansea, UK Abstract: Primary ovarian failure is common but isolated secondary ovarian failure due to gonadotrophin deficiency is rare. A few cases of isolated gonadotrophin deficiency due to congenital cerebral toxoplasmosis have been described in children. We report a case of 34 year old HIV positive African woman who developed secondary amenorrhoea following the successful treatment of cerebral toxoplasmosis. Investigations revealed that she developed an isolated gonodotropin deficiency due to pituitary lesion. The rest of the pituitary function dynamic tests were normal. To the best of our knowledge, no similar case had been reported in an adult with cerebral toxoplasmosis. Case report: She was admitted with a three week history of fever, headache and rigors in February 2010. Examination revealed she was pyrexial at 39.0°C. She was alert with the GCS score of 15/15. HIV test was positive with CD4 counts of 54 cells/mm 3 (4%), HIV RNA level was 1.2 million copies/ml, HIV genotype was subtype C with no mutations. Serological test for toxoplasma revealed that ELISA IgMnegative, Dye test -4000 IU/ml, Toxoplasma IgM (ISAGA)negative, Toxoplasma Ig Gpositive. MRI scan showed a focal ring enhancing lesion in keeping with an underlying abscess. She was empirically treated for cerebral toxoplasmosis. Her headaches subsided and remained afebrile a week later. She then developed secondary amenorrhea a month after her initial presentation. Her pregnancy test was negative. She had regular periods prior to her current illness and had two healthy children. Endocrine tests showed low oestradiol due to isolated gonadotrophin deficiency. Discussion: Our patient presented with symptoms of raised intracranial pressure without any focal neurological signs. A high toxoplasma antibody titre along with a focal ring enhancing lesion in the brain was highly suggestive of cerebral toxoplasmosis. The response to anti toxoplasma therapy confirmed the diagnosis of cerebral toxoplasmosis. The complication of cerebral toxoplasmosis depends on the site of brain lesions. Our patient developed secondary amenorrhoea a month after development of cerebral toxoplasmosis.

Conclusion: Clinicians should be made aware of this potential complication of pituitary dysfunction in patients with cerebral toxoplasmosis or any other central nervous system complications of HIV infection such as primary brain lymphoma or progressive multifocal leucoencephalopathy. Results: 209 patients had a new HIV diagnosis and followed up during the audit period. 95%(199/209) had a HBsAb result at the baseline visit. 5%(10/ 209) were diagnosed with chronic HBV infection. Vaccination was indicated in 61%(128/209). 4-dose vaccine regimes (0,1,2,6 months) were indicated in 59%(75/128), booster doses in 36%(46/128), and ultra-rapid courses were given in 5%(7/128). 47%(60/128) received at least one vaccine dose within 6 months of HIV diagnosis. 23%(30/128) had completed the appropriate vaccine course during the audit period according to local guidelines. Of those requiring the 4-dose vaccine only 1%(1/75) completed 4 doses during the audit period, with 80% receiving 2 or less doses of the 4-dose vaccine regime. After introducing the guidelines update, there was a significant improvement in the uptake of high dose 4-dose vaccine regime compared to the low dose 4dose regime (54% vs 17%, p=0.0063). 50%(15/30) of patients who completed their vaccine course had their HBsAb results tested post-vaccine. Conclusion: With the implementation of the new guidelines, uptake of HBV vaccination had significantly improved, due to the consultation, education and presentation of the new guidelines, and introduction of a new HBV vaccination proforma. There is a low rate of HBV vaccine completion especially the 4-dose vaccine regimes in our population of newly diagnosed HIV individuals. A vaccination pathway and reminders to schedule HBV vaccination appointments may improve rates of HBV vaccination completion.

Anal intraepithelial neoplasia (AIN) in a cohort of HIVpositive individuals: a retrospective data analysis D Lawrence 1 , J Vera 1 , D Richardson 1 , D Gilbert 2 , R Marchant 2 and C Morgan 2 1 Lawson Unit, Brighton, UK, 2 Royal Sussex County Hospital, Brighton, UK Background: Men who have sex with men (MSM) living with HIV are at increased risk of human papillomavirus (HPV) associated cancers including anal squamous cell cancer (SCC). Diagnosis of anal intraepithelial neoplasia (AIN) presents an opportunity to initiate monitoring and curative treatment. The characteristics of patients diagnosed with AIN are poorly understood, as are the factors associated with progression from AIN to SCC. This project aimed to describe the cases of AIN in a large urban cohort of people living with HIV in the UK. Methods: We identified all cases of AIN among patients attending a single HIV outpatient care centre. We reviewed case notes and histopathology. Results: 23 cases of AIN diagnosed between 2002 and 2016 were identified: all white MSM. Median age 45 years (range 27-59), nadir CD4 434 cells/mm 3 (4-1312), median months since diagnosis 173 (24-339) and 100% on antiretroviral therapy (ART). 16/23 (70%%) had previous anorectal STIs, of those 15/23 (65%) had HPV, 5/23 (22%) had gonorrhoea, 4/23 (17%) had HSV and 2/23 (9%) had chlamydia. Where documented, 74% were current smokers. Most patients (83%) presented with an anal lump and the majority (83%) were AIN III. 13/23 (57%) were treated with imiquimod, 7/23 (30%) with surgical excision and imiquimod, 2/23 (9%) with electrocautery and imiquimod, and one patient with AIN I with surveillance. 11 patients had repeat histology: 5/11 (45%) progressed to SCC, 2/11 (18%) improved from AIN III to II and received additional imiquimod and 4/11 had resolved entirely. Patients who progressed from AIN to SCC did so over a range of one to nine years, had comparable age (median 52, range 39-72) and nadir CD4 (385 cells/mm 3 , 4-1312) to the broader cohort but were diagnosed with HIV further in the past (210 months, 159-226). Conclusion: AIN is an emerging issue for MSM living with HIV on effective ART. A large proportion of patients have had anal STIs before AIN diagnosis. In this small cohort 45% of patients progressed from AIN to SCC. Further research is needed to clarify which patients are most at risk of developing SCC. HIV infection and receptive anal intercourse are strong risk factors for anal SCC thus the highest incidence is found in HIV-positive men who have sex with men (MSM) with anal human papillomavirus (HPV) the underlying cause in roughly 80% of cases. We aimed to describe cases of SCC in a large urban cohort of people living with HIV in the UK. Methods: We identified all cases of anal SCC amongst patients attending a single UK HIV outpatient clinic in spite of where they were diagnosed and treated. We reviewed case notes and histopathology. Results: 28 SCC cases were identified between 2001-2016 with a general increase in diagnoses each year: all were white MSM, median age 52 years (range 40-73), nadir CD4 310 cells/mm 3 (4-1312), average time of 14.8 years since HIV diagnosis and 25/28 (89%) on antiretroviral therapy (ART). 24/28 (86%) had documented sexually transmitted infection (STI) history, of those 21/24 (88%) had previously diagnosed anorectal STIs: 16/21 (76%) had HPV, 5/21 (24%) gonorrhoea, 4/21 (19%) chlamydia and 4/21 (19%) had herpes simplex virus. Common presenting symptoms were anal lump (75%), pain (21%), and rectal bleeding (17%). 25/28 (89%) had local disease, 3/28 (11%) had local nodes and there was no metastatic disease. 4/28 (14%) had previous diagnoses of AIN. Of those treated at our centre 8/13 (62%) were treated with chemoradiotherapy, 2/13 (15%) with radiotherapy alone, and 3/12 (23%) with surgery. 2/13 (15%) patients needed surgery after unsuccessful chemoradiotherapy. 2/14 (14%) were diagnosed with further AIN after successful SCC treatment. 5/28 (18%) patients have died, with two deaths attributable to SCC. Conclusion: Anal SCC is an emerging issue in MSM living with HIV on effective ART. We found that a large proportion of patients had anorectal HPV diagnosed before anal SCC but only a minority had previously diagnosed AIN.

Research and experience to establish the impact of anal cancer screening on the reduction of anal SCC in this population is urgently needed. We intend to further analyse the histopathology samples at our centre and consider annual digital rectal examinations as a screening tool.

Atypical Guillain-Barr e syndrome? Consider HIV

Background: Guillain-Barr e Syndrome (GBS) is an acute immune mediated illness causing a rapidly progressive polyneuropathy with weakness. GBS can be an uncommon manifestation of HIV. We describe two cases where patients were diagnosed and treated for GBS before being found to have acute HIV. Cases: A 57 year old female presented with a 3 week history of lethargy, difficulty mobilising, bilateral leg weakness and altered sensation in her right leg and both hands. Examination revealed reduced power, altered sensation and arreflexia in lower and upper limbs. MRI was normal and neurophysiology tests revealed sensory motor polyneuropathy with no demyelination. CSF showed raised protein and pleocytosis. Subsequently an HIV test was positive.

A 64 year old man presented with a 3 week history of pain behind his knees, lower limb weakness, recurrent falls and altered sensation in his feet. 6 weeks previously he reported night sweats, weight loss and lethargy. Examination revealed lower leg weakness (3/5), impaired sensation and absent knee and ankle reflexes. MRI spine was normal. CSF revealed a high protein and nerve conduction studies showed sensory and motor abnormalities without demyelinating features. Further investigation revealed a positive HIV test. In both cases CD4 count was high, indicating preservation of immune function. Treatment with IVIG showed minimal clinical improvement, but improvement was noted after initiation of antiretroviral therapy. Discussion: These patients presented with possible GBS; progressive symmetrical muscle weakness, arreflexia and high CSF protein level. Unexpected findings of pleocytosis and unusual nerve conduction results led to suspicion of HIV. HIV can present with neuropathy as a first presentation but distal sensory polyneuropathy or toxic neuropathy is more common. There is an association between HIV and GBS but the incidence of this is low. The incidence of GBS in the HIV population is similar to the non-HIV population. GBS typically occurs early in the course of HIV infection or at seroconversion while CD4 counts are high. The presentation, course and management of GBS in HIV seropositive and seronegative patients is similar but there is evidence of improvement with antiretroviral therapy in HIV positive patients. Background: HIV-associated TB contributes substantially to the burden of TBassociated morbidity and mortality. Survival is improved with early antiretroviral therapy (ART), following initiation of TB therapy. We investigate the quality of HIV care among individuals diagnosed simultaneously with TB and HIV. Methods: Comprehensive cohort data on adults (15 + years) diagnosed with HIV in the UK between 2010 and 2014 were linked to the national Enhanced TB surveillance system with follow-up to end of 2015. Individuals were considered simultaneously diagnosed ('co-infected') if they had a TB and HIV diagnosis within three months. Time lags from HIV diagnosis to first CD4 test date (as proxy for link to care), ARV initiation and first viral load (VL) <200 copies/mL were calculated. Results: Between 2010 and 2014, 20,548 adults were diagnosed with HIV and subsequently linked to HIV care and of these 523 (2.5%) were co-infected with TB. Median time from HIV diagnosis to HIV care among co-infected persons was 5 days [IQR 1-18.5] with 85% linked to care within 1 month. These figures were similar to without a TB diagnosis (6 days [0-20] and 81% linkage). No difference by CD4 count was observed. Median time to ART initiation was 27 days and 41 days [20-81] for co-infected persons with a CD4<100 and 100-349, respectively, and similar to that of those without a TB in diagnosis in the same CD4 strata. Among those with a CD4>350, co-infected adults started ART sooner than their counterparts without TB (median 77 days [41-281] vs 388 days ). Among those diagnosed with a CD4<100, 57% started ART within 14 days of TB diagnosis and 74% within 30 days. Following ART initiation and where VL was available, 95% of TB-HIV adults achieved viral suppression within 9 months [range 3-15 months] regardless of CD4-cell count, similar to HIV-diagnosed adults without TB. Assuming missing VL=failure, these figures dropped to 74% and 85% respectively (missing values are more likely to reflect poor data quality than viral failure). Conclusion: Linkage to HIV care following HIV diagnosis is prompt regardless of TB coinfection. Differences in ART initiation by CD4 strata reflect guidelines and uptake is overall more prompt among co-infected persons. Viral suppression following ART initiation is high for all. Observed differences in time to ART initiation will continue to reduce with the 2015 'test and treat' guidelines for both co-infected and those diagnosed only with HIV.

Auditing mortality among HIV patients in Coventry S Das 1 , S Allan 1 , H Taha 1 , S Bopitiya 1 , S Croxford 2 and A Timperley 3 1 Coventry and Warwickshire Partnership NHS Trust, UK, 2 National Infection Service, Public Health England, London, UK, 3 University Hospitals Coventry and Warwickshire, UK Background: Accuracy in reporting vital statistics is crucial. It is a legal requirement for all deaths to be reported to the national death register. Our aims were to assess the accuracy of death reporting, mortality among HIV patients and the impact of late diagnosis on mortality. Methods: Retrospective case notes review of deaths in HIV patients (Jan. 2005 to Dec. 2012). Death data were obtained from Public Health England (PHE) which receives death reports from clinicians and through the death register. PHE data were compared to death data obtained from the Trust's electronic patient records and hospital paper notes. Results: There were 46 deaths reported to death register from our hospital. Two patients died in Coventry but were resident outside Coventry and one was aged <15. There were 42 deaths reported to PHE. One patient was reported dead by a clinic outside Coventry (2009) Conclusion: This audit has highlighted serious errors in death reporting and registration can occur. We developed an action plan which was successfully implemented to ensure accurate death reporting and registration of HIV patients. A further audit, planned for 2017-18, will complete the audit cycle. Further work is needed to improve the life expectancy of people with HIV and reduce late diagnosis, which contributed to a number of deaths.

Auditing the surveillance of hepatocellular carcinoma (HCC) in high-risk individuals living with HIV A Patel, Y Gilleece and D Bradshaw Brighton and Sussex University Hospitals NHS Trust, UK Background: BHIVA recommends HCC screening for high risk patients with 6 monthly hepatic ultrasound (US) and alpha-fetoprotein (AFP). Conversely, EASL recommends screening with US alone due to minimal additional benefit of AFP & concern for false positive results. We audited local HCC surveillance practices against these guidelines. Method: This was a retrospective notes review at a HIV centre of 2450 patients, all of whom had HBV serology performed at first registration. Patients with cirrhosis and/or HBV-infection were identified by searching Fibroscan, imaging & pathology databases. US & AFP results were reviewed over a year Results: Seventy five (3%) patients had a positive HbsAg test in the 10 years prior to the period of interest for HCC surveillance, of which 36 had data available. Twenty-one patients (not HBV-infected) had cirrhosis. Therefore, 57 patients were included. Median age was 50 years (range 26-72), 53 (93%) were male; median CD4 cell count was 628 cells/mm 3 (range 27-1359); 47 (82%) had an undetectable HIV VL. For HBV-infected patients, 32(88.8%) were receiving a Tenofovir containing ARV regimen; 3 patients were on nontenofovir containing regimens; of these 2 were on Entecavir and 1 was on Lamivudine alone, as the anti-HBV therapy .One was not on therapy. Twentyeight (77.7%) had an undetectable HBV VL. Of the 21 patients with cirrhosis, six (29%) were HCV-infected and 15 had another cause for cirrhosis including alcohol. Forty-two patients (74%) had at least 1 liver scan, 39 US and 3 CT; two scans showed an HCC. Forty-two (74%) patients had an AFP level, which was elevated in 8 (19%) patients. Thirty-six (63%) patients had both an AFP and a scan (33 US, 3 CT).Twenty (95%) cirrhotic patients & 22 (61%) HBV coinfected patients were scanned. Of the cirrhotic patients 6 (30%) had elevated AFP readings ranging from 6.7-21.7kl/L. Of the HBV co-infected patients 2 (9%) had elevated AFP readings (6.1 and7.7 kl/L). Both HBV coinfected patients had normal US results, & of the 6 cirrhotic patients with abnormal AFP levels, 1 patient (17%) had a likely HCC diagnosis on US.

ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70

Conclusion: Most eligible patients were appropriately screened for HCC using US, although this was lower for non-cirrhotic HBV-infected than cirrhotic individuals. AFP did not identify any lesions not also identified on US & was falsely positive in 7(17%) patients tested. Clinicians should focus efforts on improving surveillance with US especially for HBV-infected patients.

Bone density measurements amongst young adults with perinatally acquired HIV infection in routine care F Fyles 1 , C Foster 2 and S Fidler 2 1 Imperial College London, UK, 2 St. Mary's Hospital, London, UK Background: Antiretroviral therapy (ART) enables young people living with perinatally-acquired HIV (PaHIV) to reach adulthood, with increasing focus on long-term complications of HIV and ART. Factors impacting bone mineral density (BMD) include: HIV viraemia; ART-tenofovir (TDF); steroid/depot contraceptive; failure to thrive (FTT); and HIV encephalopathy with hypertonic diplegia. We describe routine BMD scans in a cohort of PaHIV+ young adults. 

Desensitisation to emtricitabine and tenofovir in an outpatient setting for a patient with presumed allergic reaction: a case report V Gordon, D Brawley and S Baguely NHS Grampian, Aberdeen, UK Background: A 30 year old woman diagnosed HIV positive with a CD4 count of 319 commenced treatment in 2011 with darunavir/ritonavir 800/100 mg OD and Truvada 1 tab OD. Three weeks after initiation she developed a severe maculopapular rash over trunk and limbs with no systemic features or mucosal involvement. Treatment was stopped and systemic steroids initiated. Symptoms resolved and the combination of efavirenz and Truvada was commenced. Symptoms recurred and emtricitabine (FTC) or tenofovir disoproxil fumarate (TDF) were suspected as likely causes. The regimen was switched again to raltegravir 400 mg BD and darunavir/ritonavir 800 mg/ 100 mg OD. She remained on this regimen without adverse effects until 2016. In 2016 she asked if there were options to simplify her regimen due to multiple lifestyle factors. Rechallenge with a desensitising titration of FTC and TDF was discussed with the patient and subsequently arranged. Methods: Darunavir/ritonavir and raltegravir were continued. The patient had frequent pharmacist reviews and a personalised care plan addressing what to do in case of adverse effects. FTC 10 mg/ml suspension was prescribed in the following regimen; 10 mg for 2 days then increasing by 10 mg every 2 days over 47 days to maximum dose of 240 mg (equivalent to 200 mg of FTC capsules). One month FTC wash out was agreed before attempting TDF desensitisation. TDF was titrated using 33 mg/g/scoop granules over a 36 day period starting at 16.5 mg for 4 days, increasing by 16.5 mg every 4 days until 66 mg when the dose was then increased by 33 mg every four days to 231 mg. Results: Both titrations were completed uneventfully. Conclusion: Both FTC and TDF rechallenge were successful. This case highlights the immense potential value of this management option in increasing the range of antivirals available to patients.

Direct-acting antiviral therapy in HIV/HCV co-infected patients can significantly reduce liver fibrosis: a prospective cohort study S Easdon, S Edwards and M Nelson Imperial College, London, UK Background: HIV/hepatitis C (HCV) coinfection is associated with higher rates of mortality and morbidity than HCV monoinfection. Issues include more rapid progression of fibrosis, excess inflammation and reduced CD4 response to highly active antiretroviral treatment (HAART). Methods: All patients with HIV/HCV coinfection and fibrosis treated with direct-acting antiviral (DAA) therapy had a routine Fibroscan and markers of immune response to HAART pre and post therapy. Results: Between October 2015 and October 2016, 35 patients with HCV/HIV coinfection and a Fibroscan consistent with fibrosis received DAA therapy. 31 were male and mean age was 51. All were receiving HAART, 33 of which had a viral load less than 50 copies/ml and all had a viral load less than 200 copies/ml. Mean CD4 count prior to DAA therapy was 615.9 (range 75-1333) cells/ll and CD4% was 28.1 (range 6.0-50.4). Mean/median Fibroscan score was 15.6 kPa/13.9 kPa. Mean/median METAVIR score was 3.2/4 and was within the cirrhotic range in 57 percent of patients. DAA therapy was 12 weeks of Harvoni plus ribavirin (RBV) (23 patients), 12 weeks Abbvie 3D plus RBV (6 patients), 12 weeks sofosbuvir plus peginterferon plus RBV (3 patients), 8 weeks Harvoni (2 patients), 12 weeks sofosbuvir plus daclatasvir plus RBV (1 patient). All but one patient achieved SVR. Mean CD4 count at a mean of 6.6 weeks post therapy was 613.7 cells/ll and mean CD4% was 29.8. There was a mean decrease in CD4 count of 2.2 cells/ll (p=0.95) and mean increase in CD4% of 1.7 (p=0.016). Mean/median Fibroscan score at a mean of 25.1 weeks post therapy was 11.2 kPa/8.6 kPa with a mean decrease of 4.4 kPa (p<0.001). 7 individuals remained with a cirrhotic reading. Conclusion: Successful DAA therapy is possible in a HCV/HIV coinfected population with significant improvement in markers of liver fibrosis but no significant change in CD4 count and CD4%.

Efavirenz: where are we now? D Trotman, K Michie and L Ratcliffe Royal Liverpool Hospital, UK Background: Efavirenz has shown reduced tolerability compared to newer agents driven by CNS toxicity and was downgraded from a preferred to an alternative third agent in the 2015 BHIVA guidelines. It is also associated with an adverse effect on lipids and would not be considered a preferred option in patients with hypercholesterolaemia or increased cardiovascular risk. We reviewed current use of efavirenz in our cohort against the most recent guidance. Methods: We performed a retrospective case note review of 200 patients currently taking efavirenz, collecting data on demographics, time on efavirenz, co-morbidities, virological suppression and discussions regarding side effects and switch options if applicable. Results: 141 (70.5%) male, 59 (29.5%) female. Age range: 25-76 years. Patients aged 25-34=24 (12.0%), 35-44=74 (37.0%), 45-54=65 (32.5%), 55-64=24 (12.0%), 65-76=13 (6.5%). Ethnicity: 112 (56.0%) British, 77 (38.5%) African, 11 (5.5%) other ethnic origin. The majority of patients were taking Atripla=122 (61.0%), followed by efavirenz with Kivexa=60 (30%), efavirenz with Truvada=11 (5.5%), other regimes=7 (3.5%). Duration of time on efavirenz ranged from 2 months -20 years. <5 years=41 (20.5%), 5-10 years=109 (54.5%), 11-15 years=41 (20.5%), 16-20 years=9 (4.5%). 195/200 (97.5%) patients virologically supressed. CD4 count range 182-1736 (median 570). Comorbidities: depression=10 (5.0%), hyperlipidaemia=100 (50.0%), hypertension=43 (21.5%), type 2 diabetes=9 (4.5%), type 1 diabetes=2 (1.0%), cardiovascular disease (previous MI or stroke)=4 (2.0%). In 22 (11.0%) of cases a switch away from efavirenz in view of side effects had been discussed but declined by the patient. 2 (1.0%) of cases a switch was trialled but the patient returned to an efavirenz based regime. 2 (1.0%) patients a switch is currently planned for memory problems and metabolic derangement. 174 (87.0%) no discussion documented. Conclusions: Patients on efavirenz tend to be aged over 35 and taking an efavirenz based regime for at least 5 years. As expected, rates of virological suppression are high. However, a high proportion of patients have comorbidities which may benefit from a switch to an alternative third agent. Whilst some patients will decline or not tolerate a switch it is important to consider alternatives, particularly as the cohort ages.

Effect of low-dose oral vitamin D on bone mineral density changes in HIV patients H Taha, S Das and S Bopitiya Coventry and Warwickshire Partnership trust, UK Background: High prevalence of vitamin-D deficiency and abnormal bone mineral density (BMD) has been reported in HIV patients. We aimed to find out the effect of low dose oral vitamin-D replacement on vitamin-D level, parathyroid hormone (PTH) level and BMD of spine and hip in HIV patients who has vitamin-D deficiency. Methods: We compared the effect of low dose vitamin-D (800 IU) as a daily tablet in HIV-infected patients with vitamin-D deficiency. We collected information about demography, viral load, CD-4 count, risk factors for fracture, treatment history and measured 25(OH) D, PTH (intact PTH), inorganic phosphate, corrected calcium, Alkaline phosphatase (ALP) and BMD of spine and hip at baseline, 12 months and 36 months. Statistical analysis done by one-way ANOVA followed by Dunn's multiple comparison tests. Results: Total 86 patients with mean age 42.8 (+/-7.7) years, 64 (74%) black African, 48 (55%) females, CD-4 count 440.7 (+/-180.8) cells/dL, plasma VL 1.6 log (+/-2.3) copies/mL, duration of illness 56.9 (+/-34.1), exposure to antiretroviral 41.2 (+/-27.9) months were included in the analysis. Patients on tenofovir had higher PTH (0.001), on efavirenz lower vitamin-D (0.03), but no difference in BMD of spine or hip. After 36 months of follow up patients on vitamin D replacement (n=44) had significant increase in vitamin-D level (14.6+/-9.7 vs 83.3+/À44.2 p=0.0001), reduction in PTH (7.9+/-7.5 vs. 5.1+/-1.9 p=0.01) alkaline phosphatase (106+/-73.71 vs. 93.9 + /-50.4 p=0.038) and increase in corrected calcium (2.1 + /-0.1 vs. 2.2 + /-0.09 p=0.001) and BMD of hip (0.981 + /-0.19 vs. 1.005 + /-0.12, p=0.05), but not BMD of spine (0.986 + /À0.21 vs. 1.014 + /-0.12, p=0.06). In patients not on vitamin-D ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 replacement (n=42), there was increase in vitamin-D 16.0 + /À9.9 vs. 44.3 + /À12.2 p=0.01) and corrected calcium (2.12 + /À0.09 vs. 2.16 + / À0.08 p=0.02) level, but PTH, ALP and BMD of hip and spine did not change. In multivariate analysis that included all significant variables, vitamin-D replacement independently was associated with increase in vitamin-D level (OR 2.08, CI 1.03, 4.12, p=0.005), decrease in PTH level (OR 0.53, CI 0.35, 0.82, p=0.04), but not with change in corrected calcium, alkaline phosphatase, BMD of hip or spine. Conclusion: After 36 months of follow up, replacement of low dose once daily oral vitamin-D in treatment experienced HIV patients with vitamin-D deficiency can increase vitamin-D level, reduce PTH level with no changes in BMD of hip and spine.

Following evidence: is there a consistent approach to managing elite controllers after the START study L Bull, N Rockwood and T Barber Chelsea and Westminster Hospital NHS Foundation Trust, London, UK

Background: Recent studies have demonstrated the benefits of earlier initiation of antiretroviral therapy (ART) in chronic HIV infection regardless of CD4 count. Elite control of HIV infection has been defined as spontaneous and sustained maintenance of HIV RNA to <50 copies/mL in the absence of ART. Data regarding benefits of earlier initiation of ART in elite controllers (EC) is less robust although studies have demonstrated ongoing immune activation, raised cardiovascular risk and possibly more hospitalisation of EC compared to individuals on ART. We wanted to investigate current management of EC and low level viraemic (LLV) patients within our cohort. Methods: Our database was interrogated to identify any EC or LLV patients (defined here as VL<200 copies/ml) seen in the year Dec 2015 to Dec 2016. Case notes were then examined to identify any discussion/advice about starting ART with respect to contemporary data. Results: 33 patients were seen in the allotted time frame (23 EC and 10 LLV). Three elite controllers were seen only once on diagnosis and not seen again, leaving 30 patients for analysis. The median time from diagnosis in EC was 39 months; in the LLV patients it was 24 months. Median CD4 percentage was 35% (20-44%), the median CD4:CD8 ratio was 0.9 (0.3-1.3) of whom 5 had a ratio ≤0.5. Of the ECs, 8 (40%) had a documented discussion regarding rationale for starting treatment in the last year; all had declined. Of the patients with LLV, 5 (50%) had a documented discussion regarding starting ART in the last year. Four declined and one is currently considering it. There was no association between the CD4% and CD4:CD8 ratio as to whether the patient was offered treatment. Conclusion: In line with current guidelines, amongst our cohort there is no clear consensus on treating people with well controlled HIV not receiving ART, and there are some discrepancies in whether discussion takes place about treatment between physicians. We suggest, as a minimum, a documented discussion about treatment with all patients off treatment at least once a year, and that treatment is recommended at CD4:CD8 ratio of ≤0.5 as indicated by the START data. Perhaps predictably, there is a certain amount of reticence amongst ECs towards starting treatment, which may warrant further exploration.

Hepatitis B exposure, immunity and infection in newly diagnosed HIV infected men who have sex with men: a 10year analysis K Manavi University Hospitals Birmingham NHS Foundation Trust, UK Background: In the UK, men who have sex with men (MSM) should be immunised against hepatitis B virus (HBV) infection. NICE guidelines (PH43) recommend screening for and immunisation against HBV infection in a wide range of settings. Notwithstanding the recommendations, data show that the rates of exposure and chronic infection among MSM may still be high. The aim of the present study was to investigate the longitudinal rates of exposure to HBV infection, chronic HBV, and immunity to HBV infection in newly diagnosed HIV infected MSM.

Methods: All newly diagnosed patients routinely undergo screening for hepatitis B serology; hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), and hepatitis B surface antibody (HBsAb). Baseline hepatitis B serology results of all MSM diagnosed between January 2007 and January 2017 were included. Kendall's Tau was used to compare the proportions over the study decade. Results: 435 MSM were diagnosed with HIV infection in the study period. Of those 77 (18%) were HBcAb positive and considered exposed to HBV. The rate of exposure declined from 22% in 2007 to 9% in 2016, a statistically significant decline on Kendall's Tau, p=0.005. The decline was more marked between 2010 (29%) and 2011 (11%). Among the 358 MSM with negative HBcAb, 209 (58%) were immune (HBsAb>10 IU/L). The immune state of 16 patients was unknown. Over the study period, the rate of immunity to HBV increased from 47% in 2007 to 63% in 2016. The difference was not significant (p=0.056 on Kendall's Tau). Chronic HBV infection was identified in 9 (2%) MSM over the study period. The rate of chronic infection remained low and stable over the time; 2% in 2007-2009, and 2% in the 2013-2016 period (p=0.937, Kendall's Tau). Conclusion: During the 10 year observation in the cohort, the rate of chronic HBV infection has remained low in MSM newly diagnosed with HIV. The rate of exposure to HBV infection has declined significantly. This reduction cannot be accounted for by improved immunisation of MSM against HBV.

HIV and the QT: how long is too long? S Raffe, K Simmons, M Shaw, Y Gilleece and D Churchill Brighton and Sussex University Hospitals NHS Trust, UK Background: Significant prolongation of the QT interval on the electrocardiogram (ECG) can cause sudden cardiac death. A number of antiretroviral (ARV) drugs have been shown to prolong the QT interval, a particular concern when used in combination with other QT prolonging medications. A manual calculation of the QT interval, corrected for heart rate (QTc), is recommended when evaluating the risk of these medications. We evaluated the knowledge of ARV prescribers regarding QT prolonging medications and their ability to calculate the QTc. Methods: Using convenience sampling, delegates at Autumn BHIVA 2016 were asked to complete an anonymous questionnaire. This included the calculation of a QTc interval using Bazett's formula. The American Heart Association definition of a normal QTc was used (women <460 ms, men <450 ms). The "gold standard" or correct QTc was calculated using the "teach the tangent" method. Results: Thirty-three clinicians completed the questionnaire: 2 professors, 27 consultants and 2 registrars. Only 6 (18%) were able to correctly define a normal QTc. 15 (45%) underestimated the values, 2 (6%) overestimated the values, 8 (27%) stated they had no idea and 1 (3%) stated they would check google. Review of product characteristics identified 6 ARVs where a QTc prolonging effect had been seen. Efavirenz was correctly identified by 12 (36%), rilpivirine 19 (58%), atazanavir 13 (39%), darunavir 14 (42%), saquinavir 16 (48%) and ritonavir 14 (42%). Only 4 (12%) clinicians correctly identified all 6 agents and only 2 (6%) identified the 6 agents without including additional agents in their answer. 19 (58%) included a drug with no known QTc prolonging effect in their selection. Cobicistat was the agent most frequently incorrectly identified as causing QTc prolongation 14 (42%). 26 (79%) clinicians calculated a QTc from the sample ECG. The average answer was 402 ms but answers ranged widely (130-460 ms). Only 3 (9%) gave the "gold standard" answer of 459 ms with a further 5 (15%) within 10 ms. Conclusion: Significant variation was seen between HIV clinicians when manually calculating the QTc consistent with findings reported elsewhere (including among cardiologists). Our cohort generally underestimated the QTc which has implications for patient safety. Poor knowledge on which ARVs do and do not cause QTc prolongation may also be impacting on choice of ARV regimen. in the UK. The British HIV Association 2015 Audit identified low rates of monitoring of cardiovascular risk. Observational data has implicated protease inhibitors with increased cardiovascular and renal risk, but evidence is mixed. There is little UK data on prevalence of cardiovascular risk in those people living with HIV who take protease inhibitors. We aimed to describe the burden of risk in our cohort. Methods: We conducted a point prevalence audit of 149 HIV positive patients on protease inhibitor therapy from a cohort of 1200 on ART. We extracted data from our database, and local laboratory data. We used this to calculate Edinburgh CVS risk, BMI as a proxy for metabolic syndrome, and D:A:D renal risk. Results: Baseline demographics are similar to our wider cohort: 68% of the population were male, 62% were of white ethnic origin and 33% of Black ethnic origin; 45% of cases were acquired by sex between men, 47% via heterosexual sex; the mean age was 44. A resistant virus was the reason for PI use in 40%. 55% had a nadir CD4 of less than 200/mm3. In 72% of patients, ritonavir-boosted darunavir was the protease inhibitor used; 67% of patients were on a tenofovir containing regimen. 35% were current smokers. The prevalence of a recorded diagnosis of comorbidity included 20% with hypertension, 10% with chronic kidney disease, 3% with diabetes, and 1% with prior cardiovascular disease. 23% of patients had a 10-year cardiovascular risk of greater than 10%. The mean BMI was 27; 58% of patients had a BMI greater than 25. The mean D:A:D renal score in those without chronic kidney disease was 4.2%. Conclusion: The limitations are the lack of validated tools for cardiovascular risk (the QRISK is favoured by GPs and BHIVA) in HIV patients. We did not study end events such as myocardial infarctions. We did not compare against patients on other "third agents": the increased risk we observed may reflect a population trend within those on protease inhibitor therapy. This 'real world' audit of UK patients receiving protease inhibitors indicates a high burden of cardiovascular and renal risk. In addition, the BMI as proxy for metabolic syndrome is significant. This highlights an urgent need to improve monitoring and management and re-evaluate PI use in patients with wildtype virus. Background: Hepatocellular carcinoma (HCC) is a leading cause of liverrelated mortality in people living with HIV, where co-infection with hepatotropic viruses accelerates the course of chronic liver disease. The ALBI grade is a novel biomarker of liver dysfunction in HCC, however its prognostic significance has not yet been evaluated in patients co-infected with HIV. Methods: Using uni-and multivariable analyses, we studied the ALBI grade as a predictor of overall survival (OS) in a large, multi-centre cohort of patients with HIV-associated HCC recruited from 39 centres in 9 countries within the Liver Cancer in HIV study group. Results: A total of 387 patients, predominantly HCV co-infected (78%) with balanced representation of all Barcelona Clinic Liver Cancer (BCLC) stages (A=33%, B=18%, C=37%, D=12%) were recruited. At HCC diagnosis, 84% had been on anti-retroviral therapy, for a median duration of 8.8 years. The ALBI grade stratified patients into 3 groups with significantly different overall survival. Grade 1: median survival 97 months (95%CI 13-180), grade 2: 17 months (95% CI 11-22) and grade 3: 6 months (95%CI 4-9), p<0.001. A more advanced ALBI grade also correlated with lower CD4 counts and higher HIV viraemia (p<0.001). Conclusions: In this large, multi-centre retrospective study, we validated the ALBI grade as a biomarker of survival in HIV-associated HCC. The relationship between ALBI and HIV-correlated immune-suppression unveils progressive liver dysfunction as an important pathophysiologic mechanism justifying the more aggressive course observed in HIV-associated HCC.

Lowest acquisition drug cost directly acting antiviral (DAA) treatment for hepatitis C (HCV): high cure rates in a difficult to treat HIV/HCV population K Agarwal 1 , K Childs 1 , S Sawieres 1 , C Taylor 1 , S Johansen 2 , R Kulasegaram 2 and J Paparello 2 1 King's College Hospital, London, UK, 2 Guy's and St Thomas' NHS Foundation Trust, London, UK Background: In RCTs of DAAs, those with HIV/HCV co-infection have equivalent sustained virological response (SVR) rates to HCV alone. Recent data suggest that outside trials, patients with HIV/HCV may experience lower SVR rates. Methods: Data were gathered on all patients with HIV/HCV undergoing treatment (Rx) with DAAs from 1.7.14-1.12.16 at 2 centres in S. London. All were discussed by a multidisciplinary team (MDT) who decided Rx type, duration, use of ribavirin (RBV). Options were sofosbuvir/ledipasvir (SOF/LDP), paritaprevir/ritonavir/ombitasvir (PrO) plus dasabuvir (ProD), sofosbuvir/ daclatasvir (SOF/DAC) or SOF with RBV or pegylated interferon (PEG-IFN) according to NHSE genotype based guidelines. Continuous variables are expressed at median (IQR). Results: 107 patients started DAA Rx, 70 have reached the SVR 12 timepoint. Demographics see table. Of the total group, all were on ART, 21 (30%) had to alter regimen prior to DAAs due to drug-drug interactions (DDIs). Of the group who reached 12 weeks post Rx SVR, 33 (47%) were cirrhotic, including 7 (10%) with decompensation. 5 were post OLT. All had undetectable HIV RNA. 22 (31%) were previous null responders to PEG-IFN. 8 (11%) were HCV reinfections having been successfully treated before with PEG-IFN. 55 received ribavirin (RBV); RBV level 2.2 mg/L (1.6, 2.6). Baseline HCV RNA in table. 69/70 (98.5%) achieved a 12 week post Rx SVR. The one relapse was a young woman, non-cirrhotic, treated with 8 weeks SOF/LED with no RBV. Conclusions: These data demonstrate that patients with HIV/HCV and advanced liver disease achieve excellent SVR rates. Joint management by both HIV and liver physicians is essential to consider Rx duration, use of RBV and optimise DDIs. (IU/ml) 1.3 9 10 6 (4 9 10 5 , 5 9 10 6 ) 1.7 9 10 6 (5 9 10 5 , 4 9 10 6 ) Cirrhotic 41 Results: 24 (3.7%) patients with no signs of renal tubular damage other than low serum phosphate (<0.6 mmol/l) started phosphate supplements. One was on an abacavir (ABC)-based and 23 on a TDF-based regimen. The patient on ABC and three on TDF had only transient hypophosphataemia and continued their regimens. 14 switched to alternative (ABC-based or, if this was not suitable, nucleotide -sparing) regimens, and phosphate levels stabilised in all after the switch. Six remained on their TDF-based regimen and phosphate supplements; four of these later switched to Genvoyaa tenofovir alafenamide fumarate (TAF)-based regimen. The other two were eligible for TAF but had not switched at the time of the review. One of these was HLA-B5701-positive; he will be offered Genvoya at his next appointment. One had a complex treatment history with numerous ARTs and did not wish to switch to a non-standard regimen; Genvoya was not appropriate but he was recently switched to Descovy. Preliminary results in the patients who switched to Genvoya indicate that such a switch may stabilise phosphate levels, even after supplements are withdrawn (mean serum phosphate improved by 33%).

Conclusions: TAF offers a simple strategy to manage hypophosphataemia associated with TDF-related renal dysfunction. Clinicians should be more vigilant about monitoring phosphate to allow them to identify changes associated with kidney dysfunction early and take action while patients are still asymptomatic, renal dysfunction is still reversible and its consequences are not too advanced.

Markers of subclinical atherosclerotic disease in HIV infected patients Methods: Sixty adults with stable HIV infection on ART and LDL-cholesterol >3 mmol/l were recruited from three UK HIV centres. Participants were randomised (1: 1) to receive dietary advice to reduce saturated fat intake to <10% of energy intake (Diet1), or to adopt the Mediterranean Portfolio Diet (Diet2) with additional cholesterol-lowering foods (nuts, stanols, soya, oats, beans) for 12 months. Measurements of food intake, body composition, arterial stiffness, inflammation, CVR and fasting blood lipids were conducted at baseline, month 6 and 12. Between-group changes of CV risk factors were assessed using ANCOVA, with adjustments for baseline values of the dependent variables. Analysis was by intention to treat. Ethical approval was granted (13/WM/0225). Results: Baseline characteristics of the groups were comparable for age (mean 42 AE 7 years), gender (50% female), smoking status (65% nonsmokers) ethnicity (50% black African, 40% white European) and lipid profile (mean LDL 3.9 AE 0.6 mmol/l). Adherence to Portfolio components of Diet2 varied from 11 to 100% (mean 59 AE 21%). At 6 months, Diet2 participants (n=29) showed a greater increase in Mediterranean Diet Score (3.3 points, 95%CI 2.0 to 4.7, p<0.001), reduction in LDL-cholesterol (À0.4 mmol/l, 95%CI À0.7 to À0.1, p=0.01), cholesterol to HDL ratio (À0.3 95%CI À0.6 to À0.1, p=0.01), and systolic blood pressure (7.2 mm Hg, 95%CI 1.6 to 12.8, p<0.001) than those in Diet1 (n=31). Arterial stiffness, body mass index, waist circumference, levels of physical activity and high sensitivity C-reactive protein were not significantly different between groups. No adverse effects were observed in plasma levels of vitamin A, gut function, health related quality of life, or health and wellbeing. Conclusion: Dietetic advice to follow a Mediterranean diet containing plant stanols, nuts, oats, beans and soya protein produced greater improvement in diet quality, CVR, and a 10% greater reduction in LDL-cholesterol than standard guidelines to reduce saturated fat intake. Reduction in LDLcholesterol of this magnitude would translate to a 10% reduction in major vascular events.

Monitoring the fracture risk and bone mineral density of HIV-positive individuals: a single-centre audit D Hadley 1 , D Lawrence 2 and Y Gilleece 2 1 Brighton and Sussex Medical School, UK, 2 Lawson Unit, Brighton, UK Background: As HIV-positive individuals in the UK get older it is increasingly important to monitor bone health. Reduced bone mineral density (BMD) is associated with chronic HIV infection, antiretroviral therapy (ART) and traditional risk factors. BHIVA recommend assessment via FRAX score at diagnosis, prior to starting ART and every three years thereafter. FRAX has not been validated in HIV and it is unclear if HIV should be considered a cause of secondary osteoporosis. Dual energy x-ray absorptiometry (DXA) scan is recommended for those at increased risk, all women >65 and men >70 years. The BHIVA National Audit 2015 highlighted poor performance nationally. Methods: We reviewed case notes of patients over 40 attending a single HIV clinic in October 2016 and compared with a local audit in 2014. We recorded risk factors for low BMD, when FRAX scores were calculated, and DXA results. We calculated FRAX scores with and without HIV included as a cause of secondary osteoporosis. Results: 74 cases were included (47% female, mean age 52, range 40-82), mean duration of infection 178 months (2-380). 78% had a CD4>350 cells/ mm 3 (41-1292), 99% on ART, 75% of whom had ever taken TDF. 85% had a viral load <40 c/mL. Where documented, the most common risk factors were white ethnicity (68%), age ≥50 (64%), smoking (32%), and alcohol intake >3 l/day (20%). Two patients had previous fractures, one of whom was on osteoporosis treatment. Bone health was discussed in 36% of cases. FRAX scores were calculated at diagnosis in 1%, on starting ART in 3% and in 9% of patients in the last 3 years. 13% had previous DXA scans. On calculating FRAX scores without HIV as a cause of secondary osteoporosis, risk was low in 82% and intermediate in 18% with DXA recommended in 18%. Including HIV as a cause of secondary osteoporosis increased risk (low 47%, intermediate 51%, high 3%) DXA was recommended in 52%. Conclusion: These findings are similar to BHIVA National Audit figures but were significantly improved from local figures in 2014 when 1% of patients had bone health discussed. There is however huge room for improvement. Clinicians need to discuss bone health regularly and calculate FRAX scores as per BHIVA guidelines. We have launched a specialist women clinic which focuses on bone health, amongst other issues. We will work with the multidisciplinary team to further integrate bone health into our care.

Multi-drug resistant TB (MDR-TB) and HIV: patient characteristics and outcomes in resources limited settings J Meadway 1 , D Waiswa 2 , S Obbo 2 and P Olupot-Olupot 3 1 Medicines for Muheza, London, UK, 2 Mbale Regional Referral Hospital, Mbale, Uganda, 3 Busitema University, Mbale, Uganda

Background: Multidrug-resistant tuberculosis (MDR-TB) is a growing public health problem, but there is a paucity of data in resource-limited settings. Many countries adopted capacity building towards improved MDR-TB detection in the hospitals since 2010. These strategies included training of health workers, introduction of the GeneXpert MTB/RIFa molecular test for TB for early diagnosis of TB and infrastructural adjustments. We studied MDR-TB on HIV+ and HIV-patients to describe patient characteristics in these settings. Method: We assessed records of patients managed for drug resistant TB for the period June 2013 to November 2016. Through an audit, we obtained data on patient demographics, HIV status, previous history of TB, resistance type, time to culture conversion, regimen, duration of treatment and outcomes. We used basic statics to analyse these data. Results: In total 62 patients had complete records, children <14 years were 5 (8%) adults >15 years were 51(92%). The majority were males 40 (65%), HIV was positive in 26(42%). Most patients with MDR-TB 49(79%) had history of previous TB. Drug resistance was mainly to Rifampicin 34(55%), followed by Rifampicin and Isoniazid 24(39%). We noted poly resistance in 4(6.5%). During this period 18(29%) were cured, 8(13%) died and the rest were still on treatment. Conclusion: Poor treatment for initial TB infection and HIV infections were predisposing factor to MDR-TB.

with the metabolic syndrome. NAFLD is a recognised co-morbidity of HIV, but little is known about the interaction between chronic HIV infection and NAFLD. We aim to characterise our cohort with NAFLD and HIV monoinfection to identify risk factors associated with the disease. Methods: A prospective pilot study was performed to collect comprehensive clinical data from consecutive patients referred to dedicated clinics at two centres from March-December 2016. All patients underwent liver ultrasound and transient elastography. All patients with liver stiffness (LS)>7.1 kPa were invited for biopsy. NAFLD was defined as steatosis on ultrasound scan and/or controlled attenuation parameter ≥250 db/m, in the absence of excess alcohol or other causes of chronic liver disease. Univariate analysis of continuous (median (IQR), Mann-Whitney) and discrete (Chi-Squared and Fishers Exact Test) variables was performed compared to age and sex matched controls with no liver disease. Factors associated with significant fibrosis (liver stiffness ≥7.1 kPa and/or biopsy confirmation) were also explored. Results: Of 117 patients seen, 86 (74%) with hepatic steatosis were seen. After excluding secondary causes of steatosis (alcohol n=16, HCV n=2, testosterone supplements n=2), and HBV co-infection (n=1), 65 patients were enrolled. The population characteristics were: 95% male, age 44 years (40-52), BMI 28 (26-32), waist circumference 98 cm (91-110), 9% diabetic, duration of HIV infection 10 years (3-14), NRTI exposure 63 months (35-148), exposure to d-drugs 18%, CD4 nadir 295 (173-431), CD4 720 (547-923), undetectable viral load 92%. 17 (26%) had significant fibrosis defined by liver stiffness>7.1 kPa. Liver biopsy (n=5) showed NASH in 4/5 and fibrosis in 4/5 (F1 n=2, F3 n=2). Compared to controls (n=14), NAFLD was associated with increased BMI (p<0.001), waist circumference (p<0.001) and hyperlipidaemia (p=0.006). There was no association with drug exposure (including d-drugs), CD4 nadir, CD4 count or duration of infection. Age (p=0.039), BMI (p=0.026), ferritin (p=0.007) and GGT (p=0.018) were associated with significant fibrosis. Conclusions: Aging and obesity are key players in the development of NAFLDrelated fibrosis in HIV mono-infected patients independently of HIV-related parameters.

Observations and lessons learned from a newly implemented inter-trust joint HIV-endocrinology multi-disciplinary team meeting K Fernando 1 and B Jose 2 1 Cobridge Health Centre, Stoke-on-Trent, UK, 2 University Hospitals North Midlands NHS Trust, Stoke-on-Trent, UK Background: Non-AIDS comorbidities are increasingly recognised in an ageing, well controlled, HIV-infected population. Chronic immune activation, earlier ART initiation, co-infections and drug interactions are recognised contributory factors. Our HIV service provides care for a cohort of 600 out-patients. Due to commissioning changes, our Sexual Health/HIV service was relocated under a community NHS Trust provider, resulting in a geographical separation with the acute Trust. Aim: A service gap was identified with regards to specialist input for issues of a metabolic/endocrinology nature, which we aimed to bridge by creating cross-Trust working. Methods: In April 2015, a joint HIV-Endocrinology MDT meeting was convened. Cases requiring specialist input are identified from the weekly departmental HIV/Infectious Diseases MDT meeting. An Endocrinologist of the acute Trust attends our service on a quarterly basis where patient records are reviewed jointly with an HIV physician. Results: Fifty-five patients have been discussed to date (age range 25-69 years). All are taking ART. 53/55 (96%) have a CD4 count >200 cells/mm 3 (range 54-1200 cells/mm 3 ) and 52/55 (95%) have an undetectable HIV viral load. The most frequently raised issue for discussion is dyslipidaemia, in 33/55 (60%) patients. 10/55 (18%) are known diabetics and were discussed due to sub-optimal diabetes control, diabetic dyslipidaemia and/or potential ARTdiabetes drug interactions. The HBA1c range in this group is 39-103 mmol/ mol. New diagnoses of diabetes, pre-diabetes and possible reactive hypoglycaemia were identified in a further 3/55 (5%) patients. 3/55 (5%) were diagnosed with Cushing's syndrome/adrenal suppression secondary to inhaled Fluticasone -Ritonavir interaction. Other diagnoses include sub-clinical hypothyroidism and hypogonadism.

We have observed important patterns in the presentation of metabolic/endocrinology co-morbidities. Endocrinology input has proved of great benefit particularly in the management of more complex and riskassociated presentations including adrenal suppression and erratic diabetes control. This joint working also allows a consistent link with the acute Trust for in-patient consultations. Furthermore, wider learning opportunities and increased awareness amongst non-HIV specialist colleagues in the acute Trust are promoted, particularly with regards to opportunities for HIV testing.

Parkinson's disease in HIV-positive individuals: a case series from a single UK centre L Taylor 1 , D Lawrence 2 and Y Gilleece 2 1 Royal Sussex County Hospital, Brighton, UK, 2 Lawson Unit, Brighton, UK Background: HIV-positive individuals are now reaching a normal lifespan and will increasingly encounter diseases associated with ageing, including Parkinson's Disease (PD). Little is known about PD in the context of HIV; one report of 15 individuals from France showed no change in PD incidence or clinical course, but individuals reported specific hallucinations and increased impulsive behaviours. Four individuals experienced unusual motor deterioration. No interactions between antiretroviral therapy (ART) and PD treatment were found. There is no published data from the UK. We aimed to describe all cases diagnosed at a single HIV outpatient clinic in the UK. Cases: Four males with PD were identified from a total 4652 patients who had ever accessed a single HIV clinic. Two had Parkinson's Plus syndromes; one had Progressive Supranuclear Palsy and one had Lewy Body Dementia. Age at PD presentation ranged from 65-77 years. Time of HIV diagnosis to PD diagnosis ranged from 0-25 years. All individuals were diagnosed by a neurologist and had normal MR imaging of the brain bar mild ventricular prominence in one case. Differential diagnosis included HIV dementia. Three individuals experienced postural hypotension, in two cases preceding diagnosis, which has previously been linked to HIV Parkinsonism. One individual had a DaTSCAN and lumbar puncture due to diagnostic uncertainty, which showed significant changes in the basal ganglia indicative of PD and minimal CSF viral escape (91 copies/mL). Management of chronic HIV was impacted by the PD diagnosis. In one individual confusion was exacerbated by dolutegravir. Three individuals had swallowing difficulties impacting drug administration. The individual with CSF viral escape had his ART intensified to increase CNS penetration. As individuals experienced progressive disease, issues such as Power of Attorney and Next of Kin became important and with this, disclosure of HIV status. Conclusions: Similar to the previous case series, the onset of PD in these four men living with HIV occurred at a prevalence similar to that of the general population, with no clear link with HIV infection. No increase in hallucinations, impulsions, or motor deteriorations were found. While we also found that ART and dopamine treatment did not interact in our patients, challenges of managing HIV and PD included neuropsychiatric side effects of ART, swallowing difficulties and issues surrounding capacity.

The study included adults with HBeAg-positive CHB enrolled in a Phase 3 trial (Study GS-US-320-0110) comparing TAF 25 mg QD vs. TDF 300 mg QD. The associations between HBeAg loss at Week 48 with host, viral, and treatment-related factors, including on-treatment virologic suppression (Roche COBAS Taqman; lower limit of detection 29 IU/mL), were determined using logistic regression analyses. Results: Among 850 included patients, the median age was 36 yrs, 82% were Asian, and median baseline (BL) ALT and HBV DNA were 86 U/L (IQR 60-139) and 8.0 log10 IU/mL (IQR 7.0-8.6), respectively. 112 patients (13.2%) lost HBeAg and 81 patients (9.5%) had HBeAg seroconversion at Week 48. HBeAg loss was similar between the TAF and TDF treatment groups (13.8% vs. 11.9%; P = 0.519). Compared with subjects with persistent HBeAg-positivity, those with HBeAg loss were older (median age, 35 vs. 40 yrs), and had higher median BL ALT (84 vs. 115 U/L), a higher prevalence of presumed cirrhosis (Fibro-Test ≥0.75: 6.8% vs. 15.9%), and lower median BL serum HBV DNA (8.0 vs. 7.6 log10 IU/mL) (all P < 0.005). Patients with HBeAg loss had greater median decline in HBV DNA at Week 12 (4.6 vs. 4.3 log10 IU/mL; P = 0.009), but not Week 48 (6.1 vs. 6.2 log10 IU/mL; P = 0.573). In multivariate analysis, independent predictors of HBeAg loss included older age (OR per yr: 1.03 [95% CI 1.01-1.05]; P = 0.002), higher BL ALT (OR per U/L: 1.005 [1.003-1.008]; P < 0.001), and lower HBV DNA (OR per log10 IU/mL: 0.74 [0.64-0.87]; P < 0.001). HBV DNA suppression at Week 12 was not significant. Conclusions: A minority of subjects treated with TAF or TDF experience HBeAg loss with 48 weeks of treatment. Older age, higher BL serum ALT, and lower HBV DNA are associated with higher rates of response.

Prevalence of cardiovascular risk factors in women ageing with HIV: an analysis of data from the POPPY study (pharmacokinetic and clinical observations in people over fifty) S Tariq 1 , M Bagkeris 1 , C Sabin 1 , L Garvey 2 , L Burgess 2 , A Winston 2 , D Asboe 3 , M Johnson 4 , J Anderson 5 and I Williams 6 1 University College London, UK, 2 Imperial College London, UK, 3 Chelsea and Westminster Hospital, London, UK, 4 Royal Free Hospital, London, UK, 5 Homerton University Hospital, London, UK, 6 Mortimer Market Centre, London, UK Background: Increasing numbers of older women are accessing HIV services in the UK. For postmenopausal HIV+ women, the combined effects of oestrogen depletion and HIV may place them at particular risk of cardiovascular disease (CVD). We describe the prevalence of CVD risk factors in women aged ≥50 participating in the POPPY study, exploring the effects of HIV and menopausal status. Methods: This analysis is based on data from 86 HIV+ women aged ≥50 and 109 similarly-aged HIV-women. Women reporting that they had stopped menstruating were defined as postmenopausal. Chi-square tests compared the proportions with a CVD risk in each group. Results: Median (range) age of HIV+ and HIV-women was 54 (50-74) and 57 (50-86) years, respectively. Among HIV+ women, median CD4 count was 664 (58-2460) cells/lL and most (n=84) were on antiretroviral therapy. There were no significant differences in the prevalence of key CVD risk factors according to HIV status either overall, or in women who were postmenopausal (n=161, 83% of total, Table) . Only 12 (16.9%) and 11 (12.1%) of postmenopausal HIV+ and HIV-women were receiving lipid-lowering drugs (LLDs, p = 0.52), with 20 (28.2%) and 16 (17.6%) receiving anti-hypertensives (p = 0.13). Among HIV+ women there were an additional 42 and 19 women who met established criteria for LLDs or anti-hypertensives (11 and 16 of HIV-women, respectively) but were not receiving either class of drug, with no significant between-group differences. Conclusions: Within this small cohort, we report similar CVD risk factors among HIV+ and age-matched HIV-women. However, a substantial number of women with high CVD risk and/or hypertension were not receiving medication for these conditions. Clinicians should be aware of CVD risk in women ageing with HIV, and ensure they are treated in accordance with BHIVA guidelines. Conclusion: NCI was observed in 37.2% of this cohort. The unselected nature of the cohort may make this an accurate real life approximation.

M Goodwin 1 , C Leen 1 , L Panton 2 and A Kerr 2 1 University of Edinburgh, UK, 2 NHS Lothian, Edinburgh, UK Background: Abnormal liver function tests are common in HIV positive patients. This may be due to antiretroviral therapy, hepatitis B or C coinfection. Non-alcoholic fatty liver disease (NAFLD) is increasingly diagnosed in these patients. Previous studies have shown the prevalence of NAFLD to be higher than that of the normal population. NAFLD can co-exist with viral hepatitis, and could cause a faster progression to fibrosis. This study investigated the prevalence of persistently raised ALTs and characteristics associated with these in a HIV positive cohort. Methods: Patients with persistently raised ALTs were identified and the causes for these were investigated. Demographics and laboratory parameters were collected to identify factors associated with NAFLD. HIV mono-infected and HBV/HCV co-infected patients were included. Ultrasonography and transient elastography were used to identify NAFLD and liver fibrosis. Results: 4.3% (n=44) of HIV positive patients were found to have persistently raised ALTs. 11 patients were excluded from further investigation due to alcohol excess (n=8), autoimmune liver disease (n=1), out of area (n=2) or deceased (n=2). Out of the 31 remaining patients, 71% had a BMI over 25, and 12 classified as obese. 48.4% (n=15) of the patients met the criteria for metabolic syndrome. A small proportion of patients had undergone investigations of raised ALTs by their clinician. Data on patients who underwent investigations for liver disease are presented: 12 out of the 13 patients who underwent liver ultrasound had findings suggestive of some degree of NAFLD. 10 out of 12 of these patients had a BMI>25, and 11 had some amount of dyslipidemia. 6 out of 11 patients who underwent transient elastography had liver stiffness values indicating significant liver stiffness. Further data will be available in the next couple of months. Conclusion: There was a surprisingly low prevalence of transaminitis in this cohort compared to previous studies. This study found that transaminitis was frequently inadequately investigated by clinicians. More research is required into the prevalence of NAFLD within the HIV population, especially within the UK. These patients need long term follow up in order to evaluate the prognosis of NAFLD/NASH within the HIV population.

Prostate cancer in people living with HIV: outcomes in the era of HAART Methods: From a large prospectively maintained database of 633 patients diagnosed in the era of combination antiretroviral therapy (cART) with non-AIDS defining cancer, we identified 34 patients (median age 64 years, range: 46-84) with a diagnosis of prostatic cancer. Results: At the time of cancer diagnosis, the median CD4 cell count was 616 mm 3 , 33 (97%) were on cART of whom 31 (94%) had an undetectable HIV viral load. All patients presented with symptoms as there is no national PSA screening programme. The median serum PSA at presentation was 10 ng/mL and the Gleason score at biopsy ranged from 6 to 10. There was no correlation between histological grade of the tumour and CD4 cell count at cancer diagnosis (p=0.21).Three patients had metastatic disease at diagnosis whilst 31 patients had localised disease. Nineteen patients (61%) with localised disease were treated with radical therapy with curative intent, 11 with radical prostatectomy and 8 with external beam radiotherapy (of whom 3 required subsequent salvage surgery). Twelve patients (39%) with localised disease did not receive radical therapy and were monitored with close surveillance, in 10 cases this was because the localised tumour was low grade (Gleason 6). The median follow-up is only 2 years (maximum 11 years) but the 5 year overall survival is 94% (95%CI: 88-99%) and only one patient who presented with metastatic disease, has died. Conclusions: Outcomes for the treatment of localised prostate cancer in PLWH is excellent. We would strongly suggest that PLWH with localised prostate cancer are offered the same treatment strategies as patients who are HIV seronegative, including access to radical prostatectomy. In the metastatic setting, given myriad and complex drug interactions and susceptibility to opportunistic infection, we recommend PLWH needing chemotherapy are managed by clinicians with an interest in this field.

Real-world assessment of renal safety among patients with HIV infection exposed to tenofovir alafenamide S Megarity, P Rafferty, W Dinsmore, C Donnelly, C Emerson, E McCarty and S Quah Royal Victoria Hospital, Belfast, UK Background: Triple therapy comprising NRTI backbone and choice of 3rd agent remains the standard of care for treating HIV. Choosing an NRTI backbone has often involved balancing potential for renal and bone toxicity with that of increased cardiovascular (CV) risk. Where these risks are unacceptable a complex nucleoside sparing regime has been the alternative. Studies have shown tenofovir alafenamide (TAF) to be less detrimental to renal and bone health than tenofovir disoproxil fumarate (TDF) and would be an ideal choice in this situation. We present data of early clinical experience with TAF in patients with abnormal renal parameters or risk factors. Methods: Patients prescribed TAF between May-November 2016 for a renal indication were identified from clinic records. A retrospective chart review was conducted and data collected included relevant risk factors, previous ARV therapy and renal markers at intervals post TAF initiation. Results: 16 patients were prescribed a TAF based regime for a renal indication. Mean age 55 years (range 46-72). 15 Caucasian and 1 Black African. All patients were treatment experienced and switched from TDF/FTC backbone in 13 (81%), ABV/3TC backbone in 2 (13%) and NRTI sparing regimen 1 (6%). Post -switch TAF regimen was TAF/FTC/ELV/c in 10 (63%) and TAF/FTC + 3rd agent in 6 (37%) patients. Regarding comorbidities, 4 had hypertension, 3 known CV disease and 2 increased CV risk. Reason for initiation of TAF was identified as elevated uPCR in 8 (50%) patients and increased creatinine in 7 (44%) patients. Noteably 1 patient had previous renal toxicity with TDF in addition to high CV risk. Renal parameters were recorded at week 0, 12 and 24: Median creatinine clearance (CrCl) was 79.4 mL/min, 87.5 mL/min and 90.85 mL/min respectively. Median uPCR was 26 mg/mmol, 16 mg/mmol and 14 mg/mmol respectively. 1 patient with previous TDF toxicity had a CrCl of 92.6 mL/min at week 0 and 87.5 mL/min at week 12. All patients were virologically suppressed at week 24. Conclusion: Early clinical experience of TAF in mild-moderate renal impairment is similar to outcomes of large Phase III trials. Our data suggests an improvement in both CrCl and uPCR in patients with identified renal risk. Whilst it appears an ideal choice of NRTI backbone in older patients with underlying renal dysfunction or comorbidities (e.g. diabetes) more data is needed to establish its place in the treatment of those with tenofovir related tubulopathy or Fanconi's syndrome.

Reflections on a specialist HIV menopause service M Chirwa, N Taghinejadi, G Macaulay, N Nwokolo, C Bellone and N Panay Chelsea and Westminster Hospital NHS Foundation Trust, London, UK Background: 1 in 3 women living with HIV (WLWH) in the UK are aged 45-56. Data suggest that WLWH may undergo earlier menopause and suffer more associated ill-health than women without HIV [1]. Moreover, the potential for interactions between antiretrovirals and hormone replacement therapy (HRT) underscores the need to develop experience in managing this growing cohort of women. In 2015 we established a monthly HIV menopause service overseen by a gynaecologist and an HIV physician. We describe here the characteristics of WLWH attending the clinic. Results: 24 WLHIV attended. Median age at first attendance was 49; 79% were referred by their HIV clinician. 58% were Black. Mean year of HIV diagnosis was 2002 (range 1986-2015); median baseline CD4 count was 177 cells/lL. 25% had a previous AIDS defining illness. All were on antiretroviral therapy (ART); median last CD4 count was 654 cells/lL; 88% had viral load <50 copies/mL. Commonest symptoms were hot flushes (92%), menstrual irregularity (33%), labile mood/depression (33%) and vaginal dryness (25%). Median duration of symptoms before clinic attendance was 18 months. In 2 patients alternative diagnoses were sought before the diagnosis of menopause was made. 21% had early menopause (onset<45 years) or premature ovarian insufficiency (menopause onset<40 years). 50% of women who had a DEXA scan had osteopenia or osteoporosis. 83% initiated HRT or were already on HRT with the exception of 4 patients who either expressed concerns about HRT risk or no longer had symptoms at time of clinic attendance. Transdermal oestrogen with oral progesterone was the most frequently used HRT regimen. 85% of women seen at follow up described improvement in symptoms. Median time on HRT was 12.5 months. There were no HRT associated complications and no instances of ART modification. Conclusion: Menopausal women were likely to have a low nadir CD4 reflecting the number of years since HIV diagnosis and to be of African descent. Commonest presentation was vasomotor symptoms and a high proportion had osteopenia or osteoporosis. The long delay from onset of menopause symptoms to offer of treatment may be due to misdiagnosis or attribution of symptoms to HIV. Uptake of HRT was high. Methods: Retrospective analysis of people living with HIV or obstructive lung disease (OLD) aged ≥18 years who had a nasopharyngeal sample tested for respiratory viral pathogens between January 2010-August 2016. The multiplex PCR identifies: adenovirus, coronavirus, enterovirus, human metapneumovirus, influenza, parainfluenza, respiratory syncytial virus and rhinovirus. Results: Of 2024 samples identified, 1667 were PLWH and 357 had OLD. The HIV group was predominantly male (72%) and Caucasian (54%) with a median age of 45, and CD4 count of 453 cells/mm 3 (HIV load undetectable in 68%). The OLD group was predominantly female (55%) and Caucasian (70%) with a median age of 64. The proportion of samples with a respiratory viral pathogen detected did not differ significantly between the PLWH and OLD groups (558/ 1667 (33%) vs 134/357 (38%), p=0.13). This remained true when the analysis was restricted to those hospitalised with symptoms consistent with a viral respiratory illness (105/295 (32%) vs 89/281 (36%), p=0.32). Within the 692 positive samples, rhinovirus (overall 40%) was the most frequently isolated virus in both populations followed by influenza A (15%), influenza B (11%) and parainfluenza (8%). Influenza A (24% vs 13%, p=0.002) and parainfluenza 3 (10% vs 4%, p=0.005) were more frequently detected in the OLD group. In PLWH who had positive samples, a multivariate analysis showed age (OR 1.25 for each 10 years, 95%CI 1.02-1.52), female gender (1.42, 1.05-2.81) and low CD4 count (0.76 for each 100 cells/mm 3 increase, 0.70-0.84) were significantly associated with hospitalisation. In hospitalised patients with a positive sample (n=249), PLWH were more likely to have an abnormal CXR (47/ 120 vs 35/128, p=0.048) but less likely to be admitted to ICU (3/121 vs 14/ 128, p=0.008). The median length of admission was 5 days (range 0-50) in the OLD group and 6 days (0-82) in the HIV group (p=0.25). Conclusion: In our single centre study PLWH were less likely than OLD patients to have influenza A and parainfluenza detected. Our data suggest that this may reflect in part differences in age between the two populations. In PLWH low blood CD4 count was associated with hospitalisationhighlighting the importance of effective antiretroviral therapy being continued over the long-term as this population ages.

Retinal vascular calibres in HIV-positive men over 50 years compared to similar aged HIV-negative and younger HIVpositive controls L Haddow 1 , R Laverick 1 , R Gilson 1 , I Williams 1 , C Sabin 1 , I Leung 2 , T Peto 2 , J Vera 3 , F Post 4 , M Boffito 5 and A Winston 6 1 University College London, UK, 2 Moorfields Eye Hospital, London, UK, 3 Brighton and Sussex Medical School, Brighton, UK, 4 King's College Hospital, London, UK, 5 St Stephen's AIDS Trust, London, UK, 6 Imperial College London, UK Background: People living with HIV may be at increased risk of cerebral small vessel disease (CSVD). We determined the association between HIV status and retinal vascular measurements, using retinal vascular photography, a noninvasive method of measuring CSVD. Methods: White, non-diabetic men in the multicentre POPPY cohort, comprising three demographically matched groups (HIV-positive [HIV+] aged ≥50 years; HIV+ <50 years; HIV-negative [HIV-] ≥50 years) were recruited into this ophthalmic substudy. HIV+ participants were all virologically suppressed. Optic disc centred 45°colour fundus photographs were used to calculate central retinal arterial (CRAE) and venous (CRVE) calibre as well as the arterio-venous ratio (AVR). Measurements from one randomly-chosen eye per participant were compared between groups using ANOVA. The association between HIV status and AVR was estimated using a multivariable linear regression model, adjusted for age and factors associated with AVR from bivariate models (p<0.2). Results: Included were 120 HIV+ ≥50 years (median age 59 [interquartile range 54-65]), 39 HIV+ <50 years (44 [41] [42] [43] [44] [45] [46] [47] [48] ) and 52 HIV-≥50 years (60 [55-65]). CD4 count in HIV+ was median 607 (474-780). Ten-year risk of cardiovascular disease (Framingham) was 7.4%, 2.8% and 7.6% in HIV+ ≥50 years, HIV+ <50 years and HIV-≥50 years, respectively. There were no significant differences in blood pressure (BP), body mass index or lipids. Seven (5.8%) HIV+ ≥50 years had a self-reported history of stroke/TIA compared to 0 in the other groups (p=0.07). Smoking was most prevalent in HIV+ <50 years (18%, 33% and 15%, respectively, p=0.08). There were no differences between groups on any retinal vascular measure (Table) . In a multivariable model incorporating age, systolic BP, stroke and syphilis history, and recreational drug use, HIV status was associated with a 0.005 increase in AVR (95% confidence interval À0.02, 0.03). Results: Overall prevalence of hypogonadism was found to be 66%. Secondary hypogonadism was more common, observed in 63.6% of these 66 patients and primary hypogonadism was found in 36.3% reflecting the effect of HIV/AIDS on hypothalamic pituitary gonadal (HPG) axis as well as direct testicular injury. 40% patients were symptomatic historically for hypogonadism. Statistically significant association (p=0.027) between hypogonadism and the level of immunodeficiency was found with an increase in prevalence and severity of hypogonadism as the CD4 counts decrease. Significantly lower levels of free testosterone and DHEAS were found in cases of severe immunosuppression and a direct correlation between CD4 counts and the levels of free testosterone as well as DHEAS was found indirectly reflecting the negative impact of high viral load on testicular as well as adrenal androgens. Anaemia was also found to be significantly more in patients with hypogonadism. LH/FSH/Prolactin levels were higher in patients with marked immunodeficiency but their association with CD4 counts was not significant. Mean testosterone and FSH levels were significantly higher in patients on ART but the similar association with other hormones could not be ascertained.

Conclusion: Hypogonadism (primary as well as secondary) is a very common endocrinological disorder in HIV-infected male population with delayed initiation of ART and low CD4 counts being the major determinants for that.

Background: HCV/HIV coinfection leads to increased morbidity and mortality. Directly acting antivirals (DAAs) have high rates of cure even for HIV/HCV coinfected patients but complex drug-drug interactions must be managed. We examined poverty levels and treatment outcomes of HCV mono-and HCV/HIV co-infected patients in our cohort. Methods: A retrospective study of patients who started DAAs from 25/11/ 2015-24/12/2016. Sociodemographic and health data were collected including sustained virological response at 12 weeks after end of treatment.

Results: Of 227 patients, 212 (93%) were HCV mono-infected and 15 (6.6%) HCV/HIV co-infected. 65 patients had documented treatment outcome at the time of writing. Patients were predominantly male (77%) and white (89%). Mean age was 49 years. 63% of patients with mono-infection were from the most deprived quintile versus 20% for HIV/HCV co-infected. Cirrhosis was present in 32% of mono-infected and 23% of co-infected patients. Genotypes 1 and 3 were the predominant genotypes in mono-infected (67% and 28%) and co-infected (73% and 20%) patients. All HCV/HIV co-infected patients were treatment naive whilst 24% of HCV mono-infected patients had previous treatment. All HCV/HIV co-infected patients received DAAs including PROD, Harvoni (8 weeks if HCV viral load <6000 iu/mL), and Sof/Riba as per NHS England guidance at the time and their outcomes are shown in the Background: Central nervous system (CNS) toxicity is common with combination antiretroviral therapy and with efavirenz (EFV) use. Concerns exist regarding overt CNS toxicities that are not directly recognized by people with HIV (PWH) on EFV or clinicians, which could have an impact on quality of life. The aim of this study was to determine whether CNS symptoms improve in PWH without overt complains of CNS toxicities when switching off EFV. Methods: PWH receiving Atripla for at least 12 weeks with HIV RNA of <40 copies/mL, and no self-reported CNS symptoms associated with EFV were enrolled in a prospective study of switching to Eviplera. Neuropsychiatric and CNS toxicities were evaluated using CNS and sleep questionnaires. The median CNS score derived from the sum of toxicity of all grades collected in the CNS questionnaires for 10 CNS side effects (Table) , and the median Sleep score were calculated at baseline, and weeks 4 (primary endpoint), and 12 after switching to Eviplera. Cognitive function was assessed at baseline and week 4 using a comprehensive battery. Results: 41 patients (median age 47 y; interquartile range [IQR] 31, 68), predominantly male (92%) and of white ethnicity (80%) were recruited in this 4, and 12 weeks' analysis. A significant reduction in total CNS score was observed at 4 weeks (p=0.028) with a trend towards improvement at 12 weeks (p=0.064). response in between 34 and 47% of patients. The aim of the study was to investigate the immune response to hepatitis B vaccination in a cohort of HIV infected patients. Methods: All newly diagnosed HIV infected patients underwent routine screening for HBV infection at their baseline clinic visit. All non-immune patients are routinely offered immunisation against HBV infection. The vaccination course comprises Engerix â 2 mL administered intramuscularly at zero, month one, and month six. All immunised patients undergo annual screening of hepatitis B surface antibody. In the present analysis patients with negative hepatitis B surface antigen and hepatitis B surface antibody and hepatitis B core antibody were included in the study. Data on newly diagnosed patients attending the clinic between January 1st 2007 and January 1st 2017 were reviewed. Serological information of patients who completed their vaccinations course was included in the study. Immune response to vaccination was defined as presence of hepatitis B surface antibody titre of equal to or greater than 10 IU/mL 12 months after the first dose of Engerix â . Results: 415 newly HIV infected patients met the study inclusion criteria. This included 164 men who have sex with men (MSM), 239 heterosexual individuals, six intravenous drug users (IVDU), and six individuals infected through mother to child transmission of HIV. Of those patients, 354 (85.3%) received the first dose of hepatitis B vaccine. The second and third doses of vaccines were administered to 312 (88%) and 269 (76%) patients respectively. One year after the start of the vaccination course, 244 patients (91%) of those who received the planned three doses of vaccines had immunity against hepatitis B. Conclusion: In this cohort, HIV infected individuals post vaccination immunity against HBV was comparable with that of healthy individuals without HIV infection. Double dose of hepatitis B vaccine administered in the standard schedule should be offered to HIV infected patients.

The effectiveness of individualised diet and exercise advice in reducing type 2 diabetes risk in people living with HIV: a pilot investigation A Duncan 1 , B Peters 1 and L Goff 2 1 Guy's and St Thomas' Hospital, London, UK, 2 King's College London, UK Background: The burden of diabetes is increasing in people living with HIV (PLWH). Historic diet and exercise interventions aimed to mitigate risk of cardiovascular disease (CVD) in PLWH treated with antiretrovirals (ARVs), demonstrating little effect on insulin resistance. This study recruiting HIV patients with prediabetes aimed to investigate the effect of a new diet and exercise intervention on diabetes risk. Methods: Patients attending urban HIV clinics stable on ARVs and with impaired fasting glucose (6.0-6.9 mmol/l) were invited to take part. Over 6 months at 4-weekly appointments participants were advised to change their diet and exercise in order to meet 10 goals based on the Mediterranean diet and diabetes prevention trials. Advice was individualised to meet cultural and socioeconomic needs. Pre and post intervention, diabetes risk was measured using a 3-hour frequently-sampled liquid meal tolerance test. A range of secondary outcomes was measured. Data was analysed using SPSS; t-tests estimated effectiveness. Results: Of 33 participants recruited 28 completed the intervention, achieving a median of 5 goals. There were statistically significant improvements in mean 6-month change in glucose and insulin for both fasting levels (5.5% and 23.6% reductions respectively) and postprandial 3hour incremental area under the curve (17.6%, and 31.4% reductions, p=0.023 and 0.017 respectively). There were significant reductions in mean values for weight (4.7%), waist (6.2%), systolic blood pressure (7.7%) fasting triglycerides (36.2%) and 10-year CVD risk (13.5%), and a significant increase in mean HDL (12.6%) and life satisfaction score (17.6%). There was no significant change in LDL, frailty or gut symptoms. Conclusion: Despite the potential for HIV infection and ARVs to increase diabetes risk, diet and exercise change can significantly reduce this risk. Additionally the intervention significantly reduced central obesity, hypertension, triglycerides, and CVD risk, but given the cohort was heavily treated with statins the absence of an effect on LDL was not surprising. The variability in achievement of goals warrants investigation of facilitators and barriers to behaviour change. Given the effectiveness of this intervention in PLWH and financial pressures facing the NHS, a future randomised controlled trial might investigate less expensive methods of intervention delivery.

The results of the implementation of real-time PCR method for diagnostics of opportunistic infections in HIV-infected persons in Kiev regional centre for prevention and control of AIDS T Stepchenkova, O Yurchenko and I Karnets Kiev Regional Centre for Prevention and Control of AIDS, Ukraine

Objective: Improvement of laboratory diagnostics of opportunistic and HIVassociated infections in HIV-infected patients who are under medical supervision at the in Kiev Regional Centre for Prevention and Control of AIDS. Materials and Methods: Real-time PCR method for testing blood samples and body fluids. Research carried out of real-time PCR equipment (Rotor-Gene 6000) and test-kits of AmpliSense (Russia). Results and Discussion: Kiev city is one of the most affected by HIV epidemy region of Ukraine. On 01.01.2017 under medical supervision at Kiev Regional Centre for Prevention and Control of AIDS were 11 786 patients. With the rapid spread of the epidemic increases the reach of HIV-infected patients with antiretroviral therapy. Antiretroviral therapy in Kiev regional centre for prevention and control of AIDS is used by 6693 adults. The presence of opportunistic and HIV-associated patients leads to complications and reduce the effectiveness of ARV therapy (immunological and clinical inefficiency). With the presence of these diseases in patients is not always possible to determine the conventional laboratory methods. Therefore, laboratory diagnosis of opportunistic and HIV-associated infections by real-time PCR method allows assigning a necessary treatment in time and increasing the effectiveness of ARV therapy. PCR department of clinical laboratory at Kiev Regional Centre for Prevention Results: 26 co-infected patients were identified with 32 distinct infections (6 re-infections (19%)) (15 genotype (G) 1a, 2 G1b, 11 G3, 4 G4), 3 cirrhotic, 22/ 26 male with 15/22 MSM and 11/26 likely IVDU acquired. 15 patients treated locally using 27 treatment episodes. 18 infections received pegylated interferon (IFN)/ribavirin with SVR12 in 10 (56%). Subsequent regimens were: 1 IFN/ribavirin/simeprevir, 1 IFN/ribavirin/sofosbuvir, 2 AbbVie 3D â , 1 AbbVie 2D â , 5 Harvoni â +/À ribavirin with SVR 12 in 10/10 (100%). Hence, of the 16 patients treated to date SVR12 was achieved in 14/16 (87.5%). Of the remaining 12 infected patients: 2 are scheduled to commence treatment imminently, 4 G3 await funded IFN-sparing therapy, 2 treated elsewhere, 2 left region and only 2 poorly engaged with services. Side effects with IFNcontaining regimens were numerous with only one occasion when therapy was discontinued in a non-cirrhotic G3 patient who stopped interferon after 2 weeks to remain on sofosbuvir/ribavirin to completion at 12 weeks (SVR12 ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 negative). Dose reduction of ribavirin was undertaken according to levels of haemolysis to preserve haemoglobin. One patient developed antibody positive auto-immune myositis at cessation of treatment, probably precipitated by IFN. Antiretroviral therapy (ART) was commenced prior to hepatitis C treatment in 25/27 (93%) cases with care taken to avoid drug interactions (DI). All treated with direct acting antivirals (DAA) were discussed in a hub MDT as per commissioning arrangements. 2 patients required transient switch in ART to avoid DI whilst allowing for lowest cost acquisition hepatitis C therapy. 3 had had ART tailored to avoid DI in preparation for DAA therapy, highlighting the advantages of an integrated Infectious Diseases service. Conclusion: Our cohort demonstrates remarkable efficacy in real world data with SVR12 of 100% in patients treated with DAA therapy. The transformation in outcome in recent years is well demonstrated along with the ability to effectively manage complex co-infection in a DGH setting through an ID-led service with excellent patient engagement, few side effects and no major drug interactions. A high re-infection rate in this cohort was observed.

Weight gain in patients using integrase inhibitors: an emerging class side effect S Bhaduri 1 and M Roberts 2 1 Worcestershire Health and Care Trust, UK, 2 Worcestershire NHS Acute Trust, UK Background: The HIV service hosts a semi urban cohort of 260 patients. 69 patients are using integrase inhibitors (INSTI) as part of their antiretroviral regime. Some patients have complained of weight gain on this regime. We explore this observation further across this class of drugs. Methods: Case notes of patients using an INSTI were scrutinised for evidence of weight gain. We identified 5 patients where there was evidence of significant weight gain. Results: Case 1: 58 year old Caucasian female with co-morbidity of rheumatoid arthritis (RA) switched from Atripla to Stribild. After 12 months exposure to Elvitegravir 9 kg weight gain was noted. After switching to Dolutegravir/Truvada, the weight increased a further 9 kg in 6 months. The CD4 remained stable with viral load suppression and no additional steroid requirement for RA. The patient was switched from Dolutegravir to Evotaz with weight reduction of 7 kg in 2 months. Case 2: 42 year old Black African male commenced Atripla but switched to Triumeq due to worsening renal function. His weight increased 16 kg in 9 months with a stable CD4 count 369/mm 3 and viral suppression. Case 3: 53 year old Caucasian male commenced Truvada/Darunavir/Ritonavir. Later Darunavir was switched to Dolutegravir with weight gain of 13 kg in 1 year with a stable CD4 and viral suppression. Dolutegravir was switched to Nevirapine with complete reversal of weight gain. Case 4: 56 year old Caucasian male, diagnosed with CD4 35/ mm 3 on Truvada/Raltegravir, switched to Triumeq/Darunavir owing to resistance with weight gain of 5 kg after 2 months when CD4 stable and viral load suppressed. Case 5: 37 year old Caucasian male diagnosed with CD4 34/mm 3 , viral load 1.5 m copies/ml. Commenced Truvada/Darunavir but switched to Triumeq for simplification. 4 months later weight gain of 13 kg was noted but CD4 had increased to 279/mm 3 with viral suppression. Conclusion: In this case series of 5 patients we describe an association between weight gain and INSTI exposure across 3 different INSTI. In 2 cases we have demonstrated reversal on switching off INSTI. An ACTG study highlighted the effect of Raltegravir exposure and weight gain which persisted despite adjusting for immune status. In two of our cases weight gain may have been further compounded by late diagnosis and immune reconstitution but overall this data supports the recent literature for INSTI exposure and weight gain, and furthermore suggests a possible class effect of weight gain on INSTI. This project aimed to review the demographics of these patients, the reasons for late presentation and the obstacles to timely diagnosis, and suggest improvements to primary, secondary and tertiary care services to reduce rates of late diagnosis. Methods: Retrospective analysis of case notes for adult patients diagnosed with late HIV between 1st June 2014 and 1st June 2016. All patients had a baseline CD4 count of 350 cells/mm 3 or below and were selected from a GUM clinic and infectious diseases unit in the same city. Results: 38 sets of notes were identified across two sites that met the criteria but 4 were not available, giving a final cohort of 34 patients. Baseline CD4 counts ranged from 0-350 cells/mm 3 and had a median of 205 cells/mm 3 . 16/ 34 (47%) patients identified as men who have sex with men (MSM), 16/34 (47%) as heterosexual and 2/34 (6%) as bisexual. 16/34 (47%) were tested due to being symptomatic or unwell. Of those cases where route of transmission was clearly documented (32/34, 94%), being an MSM was the suspected route of transmission in 18/34 (53%) cases and heterosexual in 12/ 34 (35%). 14/34 (41%) had a test indicator condition at diagnosis including sexually transmitted infections such as chlamydia, cervical intra-epithelial neoplasia stage III, and mononucleosis-like syndromes. 4/34 (12%) had an AIDs defining condition including Kaposi's sarcoma, pneumocystis pneumonia and HIV encephalopathy. Conclusions: Both MSM and heterosexual populations are at risk of late diagnosis, as well as those from outside of the UK. A significant proportion of patients presented with severe AIDs defining conditions, suggesting missed HIV testing opportunities in other health services. We suggest that earlier testing would have led to fewer late diagnoses and less HIV-related morbidity; further local evaluation is required. Methods of expediting HIV testing include promotion and provision of home HIV testing, improved access to HIV testing for at-risk groups and education of healthcare professionals around HIV risk, sexual history taking and awareness of HIV indicator conditions. (Optimal use of other HIV prevention strategies, such as partner notification and pre/post exposure prophylaxis may also contribute to a reduction in late diagnoses).

ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 P109 AIDS in Edinburgh: a case series on ongoing diagnostic challenges D Raha 1 , C Mutch 2 and M Mackenzie 2 1 Chalmers Centre, Edinburgh, UK, 2 Regional Infectious Diseases Unit, Edinburgh, UK Background: In the year 2015 at the Regional Infectious Diseases Unit of Edinburgh (RIDU) there were four deaths due to AIDS. We present a review of these patients. Methods: Case note review. Results: Multiple risk factors for delayed diagnosis were identified i.e.: Men who have Sex with Men (MSM); movement between health boards within and out-with the UK. All 4 patients presented with non-specific symptoms which were initially misdiagnosed as common presentations. Patients continue to present with indicators for HIV testing yet diagnosis is often delayed, worsening outcomes. Initial presentation of AIDS is commonly with non-specific common symptoms. As such it is vital to maintain a high degree of suspicion. The lack of a sexual health history as part of the routine medical clerk-in can contribute to a delay in HIV diagnosis as risk factors will not be identified. It remains vital to educate clinicians to recognise features suggestive of HIV/AIDS, and to increase awareness of the BHIVA guidelines on testing.

Barriers to HIV testing in patients with confirmed oesophageal candidiasis F Carlin Royal Liverpool University Hospital, UK Background: Earlier HIV diagnosis is associated with improved health outcomes, reduced admissions and health costs, and reduced rates of transmission. The BHIVA, BASHH, BIS 2008 testing guidance recommends testing for patients with oesophageal candidiasis, which occurs more frequently in HIV positive individuals at lower CD4 counts. The aim was to find out how many patients with oesophageal candida on gastroscopy (OGD) were tested for HIV and to identify possible barriers to testing. Methods: Data from the hospital endoscopy unit for the first 6 months of 2016 was reviewed for cases of candida on OGD. Patients were included based on endoscopy findings or histology. Lab results and case notes were checked looking for evidence of HIV testing within three months of the OGD, or discussions offering testing after OGD. After results were collected, a brief survey was conducted within the gastroenterology team regarding barriers to testing. Results: 78 patients were identified with candida, 6 excluded due to negative histology. Equal split men and women. 14 (19%) had HIV tests. Only one OGD report recommended HIV testing. No surgical patients were tested, 7% GP referrals, 40% AMU, 36% general medicine, 13% gastroenterology referrals tested. Some patients who were not tested also had symptoms of unexplained anaemia, weight loss or Hepatitis B or C all of which are listed as indicator conditions in the 2008 UK National Guideline for HIV testing. Patients were more likely to receive an HIV test if under 50 yrs old. Oesophageal candidiasis was often attributed to inhalers when no other cause could be found and patients with an active malignancy were less likely to be tested. Of note, many malignancies are more common in HIV positive individuals. Barriers to testing included lack of knowledge of the guideline and its recommendations, concerns regarding cost of testing and requirement of specialist test counseling for patients including time constraints and appropriate follow up. Conclusion: Only 19% of patients with confirmed oesophageal candida were tested for HIV highlighting missed opportunities for diagnosis. Many healthcare professionals are not aware of the National Guidelines for HIV testing and the indicator conditions for which testing is recommended. This highlights the need for increased and regular staff education across hospital specialties and General Practice to raise awareness of the guidelines and promote HIV testing as part of routine practice. Methods: Deaths among HIV patients occurring in 2015 were reported by London HIV care centres. Data were collected on demographics, diagnosis information, cause and place of death, most recent CD4/viral load (VL), ART status and reported adherence. Clinicians were asked whether each death was expected, defined as patients who were expected to die (eg. those receiving planned end of life care or with a terminal condition), or unexpected (eg. late presenters admitted at diagnosis and not responsive to treatment). Deaths were categorised using the CoDe Protocol. Results: 170 deaths were reported among HIV patients from 15/18 care sites, 70% were among men. The median age at death was 52 years for men and 47 for women. Most people died in hospital (60%; 36/157) or at home (23%; 36). Over 90% (141/156) of people were on ART and adherent (85% 121) at their last clinic visit. Of those not on ART, 79% (11/14) had a CD4<350 cells/mm 3 and 92% (12/13) a VL ≥200 copies/ml. Over half of deaths (53%; 77/146) were unexpected. Of expected deaths, 57% (39/68) died in hospital. Median time from diagnosis to death was 9 years, with 30 (18%; 30/166) people dying within a year. Cause of death among everyone, those dying within one year and unexpected deaths can be seen in the table below. Where cause was known, the majority of deaths were from AIDS (31%; 45) and non-AIDS cancers (21%; 31). AIDS-defining illness accounted for 70% of deaths occurring within one year of diagnosis and 30% (20/77) of unexpected deaths. Those who presented with an OI had a significantly lower CD4 count (p: 0.001), higher HIV-1 viral load (p: 0.009) and were less likely to be engaged in care (p: <0.001). IVDU mode of acquisition and HCV co-infected individuals were more likely to be admitted for a non-HIV related illness (76%, p: 0.016 and 51%, p: <0.001 respectively) while the heterosexual risk group were more likely to present with OI (31% OI vs 26% non OI, p: 0.016).

Discussion: An improved care package for the IVDU, HCV co-infected cohort needs to be developed to optimise patient care and prevent hospital admissions and healthcare costs. There is also a need for improved screening and immediate ART given the on-going rates of OIs seen in our cohort.

Factors associated with delayed linkage to care following HIV diagnosis in Western Europe Results: 148 individuals were included in analysis. There were 120 (81%) men and 14 women. The mean baseline CD4 was 452 cells/lL (range 8-1079) and mean HIV VL was 398201 copies/ml (range 19-9999999).The median time from HIV diagnosis to ART initiation was 28 days ). 51% of individuals started ART within 28 days and 90% within 3 months. Rapid ART initiation was associated with lower baseline CD4 (p=0.009; 95% CI: -173 to -25), high baseline viral load (p=0.015; 95% CI: 109497-993518) and primary HIV infection diagnosis (p=0.027).The mean time to ART for an individual diagnosed with primary HIV was 18 days (range 0-45). Rapid ART initiation was not associated with age, gender, ethnicity or co-infection with Hepatitis B or C. Conclusion: Over half of individuals started ART within 28 days of HIV diagnosis. Factors associated with rapid ART initiation included low CD4, high VL and primary HIV infection. Further investigation into delayed ART initiation is underway.

HIV partner notification: an audit against BASHH standards Background: HIV diagnosis and care is improving, however it is still a growing epidemic. To reduce this several approaches need to be taken including increasing HIV testing rates. It is estimated 13,500 people living with HIV in the UK are unaware of their infection and risk of transmission is higher when people are not on highly active retroviral therapy (HAART). It is also important to identify those who may already be HIV positive before starting them on HIV post exposure prophylaxis (PEP) to reduce risk of inducing resistance to antiretroviral therapy. HIV POCTs can provide faster results than standard serology testing and may be more acceptable to patients who suffer with needle phobia or who are anxious awaiting results. Therefore they can be used prior to prescribing PEP and it is anticipated they will increase HIV testing. Methods: To ascertain the utility and performance of the Alere HIV POCT it was piloted at a local sexual health department between 09/10/15-15/01/16. A HIV POCT was performed for those who were starting PEP, needle phobic, too anxious to await standard serology results or for another significant reason. A proforma was completed for each HIV POCT and a logbook completed. Results: In total 39 patients had a HIV POCT. There were several risk factors for HIV transmission including MSM (33%), HIV positive partner (37%) and partner from high prevalence area (3%). The most common reasons for HIV POCT were pre PEP (59%), anxiety awaiting standard serology (13%) and other significant reasons (13%). 95% of the HIV POCT results were negative and 5% were antibody positive. 92% were confirmed by standard serology HIV testing, 3% were not confirmed and 5% did not have confirmatory serology taken. Conclusion: All of the HIV POCTs where confirmatory serology was taken were confirmed apart from just 1 which accounted for the 3% not confirmed. That 1 test was performed by an untrained staff member. In future all HIV POCTs would only be performed by trained staff. The 5% of HIV POCTs where confirmatory serology was not taken was due to needle phobia. From the results it would appear the Alere HIV POCT is a sensitive and specific test. Introducing the Alere HIV POCT would decrease clinical risk, may increase up take of HIV testing as they may be more acceptable for patients with needle phobia and may be cost effective by reducing follow-up attendances for results in high risk patients.

HIV testing in the emergency department: an important and distinct target population (66/261) Sexual Health clinics, 5% (13/261) community care clinics, 13% (35/ 261) GP, 10% (26/261) in secondary care, and 6.5% (17/261) were diagnosed through partner notification. The ED population had more heterosexuals than the non-ED population (75% vs 59%, p=0.022). There was no significant difference in gender or ethnicity in both groups. In the ED population, 23% (24/104) were seroconverters. The median CD4 count not significantly different between the two groups (377 vs 381, p=0.25) but 55% 57/104) were admitted as inpatients following their presentation to ED. 16% (17/104) had one or more presentations to ED within 12 months prior to being diagnosed. 64% (67/104) of the ED population were linked to see a clinician within 2 weeks of HIV diagnosis. Conclusions: This analysis confirms the importance of targeting the ED population for HIV testing. The ED population has a larger proportion of heterosexual males, which is a traditionally a hard to reach group for HIV screening. High rates of primary infection continue to be found in this population.

HIV testing of patients with indicator CNS infections in a large teaching hospital in England diagnosed late despite a variety of indicator illnesses. UK and European HIV testing guidelines include a list of indicator conditions for HIV testing, including AIDS defining neurological conditions. Testing is also recommended for patients with aseptic meningitis or encephalitis and all those with invasive pneumococcal infections. The aim of this study was to review HIV testing of patients with aseptic meningitis or encephalitis as well as with specified organisms causing meningitis, as per guidelines. Methods: Clinical and laboratory data were collected between December 2012 and June 2016 for patients with encephalitis and meningitis in a single teaching hospital which also has a tertiary referral infectious disease unit. Patients were recruited prospectively according to predefined definitions for meningitis and encephalitis and stratified according to aetiologies. Data were reviewed to ascertain whether HIV tests had been performed and their outcomes. Results: 63 patients were recruited of whom 42 met the inclusion criteria. Of these 26 had aseptic meningitis or encephalitis and 16 patients had other infections including 6 pneumococcal, 7 varicella zoster, 1 JC virus, 1 Mycobacterium tuberculosis and 1 Cryptococcus neoformans. Overall, 24/42 (57%) had a HIV test performed of which 3 were positive (12.5%). When a specific organism was identified 11/16 (68.8%) were HIV tested. In the aseptic group, 5/7 (71%) with encephalitis and 8/19 (42%) with meningitis were tested. In 26 patients for whom location was identified, HIV tests were performed in 8/10 (80%) of patients under infectious diseases, 3/3 (100%) in intensive care and 3/8 (37.5%) under general medical teams. Conclusions: Modern guidelines recommend HIV testing for all patients with aseptic meningitis or encephalitis or with defined CNS infections. In this single teaching centre only 37.5% of patients are tested on general wards compared to 80% on specialist wards. At best, 68.8% of patients with proven CNS infections were tested, and only 50% of those with aseptic meningitis or encephalitis were tested. Further work is needed to promote HIV testing in general medical and emergency room settings.

How can we use phylogenetics to facilitate clinical case finding and partner notification in HIV? Lessons from a systematic review of its use in stigmatised infectious diseases L Mulka 1 , JH Vera 1 , JA Cassell 1 and AJ Leigh-Brown 2 1 Brighton and Sussex Medical School, UK, 2 University of Edinburgh, UK Background: Phylogenetic information provides new horizons for clinical case finding in HIV, but raises issues of acceptability, privacy and even criminalisation. We reviewed studies describing the use of phylogenetics to directly inform case finding of undiagnosed contacts in community acquired stigmatised infectious diseases. Methods: A search in MEDLINE, Embase, CINAHL and PsychINFO for articles where phylogenetics have been used to facilitate case finding in sexually transmitted infections, TB, HBV or HCV, published until July 2016 in English. Results: 26 of 6042 papers screened met the inclusion criteria; 17 TB, 9 HIV. An additional 18 studies reported using phylogenetics to investigate discrete HIV outbreaks and trace sources but did not explicitly report its role in case finding. Case finding strategies included confirming the source of an outbreak to prompt wider investigation (HIV); contact tracing of phylogenetically clustered cases (TB, HIV); combined cluster and geographical information to target screening (TB); screening informed by discrepancies between genotypic and epidemiological data (TB); phylogenetic characterisation to inform a screening intervention (HIV); using linked epidemiological data to identify of a source (HIV); and contact tracing with genotype matching to a case with rapidly progressive disease (HIV). Facilitators included sharing molecular surveillance data to establish community support in targeted TB screening. Barriers included delayed results, time lapse between cases and refusal of access to premises for screening, however patient barriers were rarely reported. Ethical issues included media coverage of an HIV sources identity. Conclusion: Phylogenetics-informed approaches to case finding are feasible in stigmatised infections. However studies reporting their use in clinical and public health practice provide limited information on patient related barriers, acceptability, or on ethical challenges such as identification of "core" transmitters or criminalisation. Research into patient views on acceptability, risks and preferred approaches to using phylogenetic information for case finding in HIV is needed to inform future interventions.

Innovative HIV testing in the workplace J Hand 1 , C Evans 2 , H Blake 2 , B Hussain 2 and D Rowlands 3 1 LASS, Leicester, UK, 2 University of Nottingham, UK, 3 Design Redefined, East Midlands, UK Background: Funded by Public Health England this project provided HIV tests as part of a series of health/wellbeing events at workplaces along the M1 distribution corridor, targeting low waged workers on shifts with long hours. Although many UK organisations offer employee health checks, they do not include HIV testing. It was one of the first initiatives in the country to include HIV within employee health checks. The project was delivered in the East Midlands by 5 voluntary sector organisations and took place over a 9 month period. It aimed to reach men in the workplace (particularly migrant men from sub-Saharan Africa and Eastern Europe), and had an initial target of undertaking 300 HIV tests. Employees attending the health events were also able to receive a series of 15 additional text messages providing further information about HIV, Prep, Hep C, safer sex, general health and wellbeing and GP referral. Evaluation Method: The evaluation explored the feasibility, acceptability and potential sustainability of workplace HIV/wellbeing interventions, from multiple stakeholder perspectives (employees, companies and project partners). It adopted a mixed methods design using questionnaires, interviews, text messages and project monitoring data. Results: 776 employees from 50 different countries attended 20 workplace health events held in 11 different companies; one third of attendees were migrant workers. 52% of attendees undertook an HIV test. 75% of attendees had never had an HIV test before. 96% considered HIV testing to be an acceptable element of workplace health check and 79% felt they had learnt something new about their health. 465 (60%) of attendees signed up to receive the follow up text messages and 21 of these reported seeking an HIV test after the event. Conclusion: HIV testing in the workplace is highly acceptable. The events were able to reach a diverse group of employees, including those who had not previously tested. The project also suggests that mobile phone text messaging is an acceptable and well-received adjunctive method of motivating people to test and take action. National policies and guidance on workplace health should include HIV testing. This would also provide strong support and credibility to any local initiatives that aim to undertake HIV testing in the context of workplace health initiatives. There is a need for more research to explore different models of incorporating HIV testing into workplace health and wellbeing initiatives.

Is it acceptable to ignore national testing guidelines? Current testing practice in Lothian 8 years after BHIVA national testing guidelines were published M Cevik 1 , C Leen 1 and D Raha 2 1 Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK, 2 Chalmers Sexual Health Centre, Edinburgh, UK Background: In the UK, almost 90% of patients diagnosed with HIV had initiated ART, with 93% of those on ART having a suppressed viral load. However approximately one-fourth of all HIV infections in adults still remain undiagnosed and one-fourth of newly diagnosed individuals are late presenters. We aim to assess the newly diagnosed individuals in Lothian where prevalence is over 0.2% with no agreed policy to screen for HIV in order to understand current testing practice. Methods: Using our dedicated HIV database we included all new presenters to our services between April 2015 and April 2016. Data were retrospectively collated through electronic patient records. Descriptive statistics were performed to examine demographics, baseline characteristics and treatments. Results: We identified 51 individuals (3 female) who were newly diagnosed with HIV. Median age was 35 years (20-73) with 3 individuals >65years. 17 individuals were diagnosed in GUM clinic, 14 in GP practice, 10 in secondary care, 6 through outreach services and 3 using self-testing kit. 21 individuals diagnosed through routine screening, 5 contact tracing and 24 individuals presented with clinical symptoms. Median nadir CD4 cell count was 326 cells/ mL. However, we observed significant differences in those diagnosed in various settings (Table 1) . Individuals diagnosed in secondary care and those who used ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 home testing kit had significantly lower median CD4 counts, 81 and 114 cells/ mL, respectively. More than half of our cohort (28) had CD4 count <350 cells/ mL, 10 (36%) of those presented with AIDS defining illness and 11 individuals (39%) presented to a health care facility in the past year before the diagnosis with a clinical indicator of HIV infection. Overall 13 (25%) individuals had CD4<200 cells/mL, 4 (8%) out of those died within 3 months after diagnosis due to an AIDS defining illness. Conclusion: Early diagnosis is critical to improve morbidity and mortality, and also for the prevention of onward transmission. Late diagnosis has been associated with longer hospital stay and increased cost to healthcare services. In this cohort one-fourth of patients had CD4 count <200 cells/mL and more than half had CD4<350 cells/mL. 39% of late presenters had contact with health care prior to HIV diagnosis representing missed opportunities for earlier diagnosis. We believe routine testing in all relevant settings should be offered as per National guidelines in order to reduce undiagnosed HIV infection at late diagnosis.

Late presenters with HIV in Newcastle: a 10-year audit of newly diagnosed HIV (2007 HIV ( -2016 N O'Keefe 1 , T Gentry 1 , E Hurn 1 , A Daniels 1 , A Wilkinson 1 , A Radford 1 , P Falkous 1 , I Bittiner 1 , PY Tan 1 , K Golds 1 , N Sankar 2 and E Ong 2 1 Newcastle University Medical School, UK, 2 Newcastle Hospitals NHS Trust, UK

Background: This audit aims to identify late presenters and missed opportunities for earlier HIV testing over 10 years, and whether the UK 2008 testing guidelines has had an impact on early diagnosis. Method: This 2016 study is a retrospective case note audit of 32 patients newly diagnosed with HIV that have presented as compared with previous years since 2007. Patients with an initial CD4+ count of <350 were classed as late presenters. CD4+ counts of <200, or AIDS, were classed as advanced disease.

Results: In 2016, there were 17 newly-diagnosed patients in the ID department and 15 in GUM. Of the patients who presented to ID, 76% presented late and 47% had advanced disease -6 had previous identifier disease. At GUM 27% presented latethere were no patients with advanced disease or previous indicator disease. Conclusion: Late HIV presenters remain a challenge in Newcastle. The UK 2008 HIV testing Guidelines do not appear to have made any impact over the past 10 years as a significant number of newly diagnosed late patients (76%) especially in the ID department had missed opportunities for earlier HIV testing and were not offered.

Over half of people in HIV care in the United Kingdom by 2028 will be aged 50 years or above Source  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID  GUM  ID Background: The number of people aged ≥50 years living with HIV in the UK is increasing. Older people living with HIV (OPLWH) are more likely to have been diagnosed late (with a CD4 count of ≤350cells/mm 3 or with an AIDS defining illness within three months of their diagnosis). Information about sexual health service utilisation of OPLWH prior to HIV diagnosis is limited. This study aims to assess sexual health service utilisation of people living with HIV (PLWH) aged <50 y compared to ≥50 y prior to an HIV diagnosis. Methods: The study was conducted at a single HIV outpatient centre in the UK. PLWH who had been diagnosed within the 5 years prior to August 2016 were identified from the clinical database. Demographic and HIV clinical variables, including baseline CD4 count, date and place of HIV diagnosis, and number of visits at a local sexual health clinic were gathered from the clinical database. Statistical tests were carried out on this data to determine differences between those ≥50y and <50y. Significance is defined as P=≤0.05. Results: 576 PLWH were included. 78 (13.5%) were ≥50 y, and the remaining 498 (86.5%) were <50 y. PLWH ≥50 y had a significantly lower number of episodes treated in sexual health per person in the 5 years prior to HIV diagnosis than the younger group (P=0.016). Late diagnosis was seen in 53.8% of those ≥50 y compared to 26.1% of those <50 y (P=0.001). Table 1 shows the facility of HIV diagnosis for both groups of PLWH, where this information was available. PLWH ≥50 y were significantly more likely to receive a diagnosis in primary or secondary care, whereas those <50 y were significantly more likely to be diagnosed in sexual health. We ascertained immediate cause of death in 40 of the 41 cases. Of the 40,18 deaths were directly related to HIV, and 22 were not. Of the 22 deaths not directly related to HIV, the most common immediate causes were malignancy (9), suicide (3), and sepsis (3).

Within the 18 HIV related deaths, the most common immediate causes were multi-organ end-stage HIV disease (4), lymphoma (4), and sepsis (4). Of these, 7 patients were under care but had an untreatable complication, 4 were under care but had chosen not receive treatment, 1 was known to have HIV but re-presented too late, and 6 were diagnosed too late for effective treatment. Thus, 6 of 41 deaths (15%) were directly related to late diagnosis; this compares to 24% nationally in the previous audit. Overall, 8 (20%) patients were diagnosed <3 months before death; compared to 23% across all centres in the 2005-2006 audit.

Conclusion: Compared to the 2005-2006 audit period, patients are dying at more advanced ages, with higher CD4 counts, and more frequently of causes not-directly related to HIV. Non-HIV associated malignancy has become a leading cause of death in our cohort. Late diagnosis remains an important contributing factor to mortality, indicating that there are still preventable deaths. We recommend that mortality should be reviewed at network level meetings and changes made to reduce preventable deaths.

Trends in prompt ART initiation among gay and bisexual men diagnosed at high CD4>350 cells A Brown, P Kirwan, Z Yin, C Chau and V Delpech Public Health England, London, UK Background: In the UK, antiretroviral therapy (ART) coverage is 96%. ART at diagnosis is now considered best practice for public health as well as clinical purposes. In 2015, 75% of gay/bisexual men starting ART had CD4>350 compared to 50% among heterosexuals. This suggests gay/bisexual men are more likely to start ART for treatment as prevention (TasP). We present demographic trends in ART initiation among gay, bisexual and other men who have sex with men ("men" hereafter) with CD4>350. Methods: The UK has a comprehensive national open cohort of people with HIV from the point of diagnosis, with clinical updates from all sites. We analysed data on men starting ART (20,877) between 2010-2015 where both ART start dates and CD4 counts prior to ART start were available (66%: demographics similar to all men). We described trends in ART uptake and identify predictors for prompt initiation (<6 months from diagnosis) among those starting ART with CD4>350. Men diagnosed in the latter half of 2015 were excluded from multivariate analyses due to short follow up time. Results: The (adjusted) number and proportion of men starting ART with CD4>350 rose from 41% (942/2,298) in 2010 to 75% (2,930/3,906) in 2015 (equivalent figures for CD4>500 were 17% and 48%, respectively). Overall, 8,073 men starting ART were included in the study: 38% (3,405/8,073) with a CD4>350 CD4 started ART within 6 months and 25% (2,012) within 6 weeks of diagnosis, with improvement in more recent years (Figure) . The factors associated with prompt initiation among those with CD4>350 included: recent year ( Conclusions: Trends in CD4 at ART start reflect the evolution of national treatment guidelines. The impact of TasP will be maximised with prompt ART initiation following diagnosis. The variation in prompt initiation at diagnosis by region and other demographic factors requires further investigation to ensure equitable access to ART for public health purposes 

Using technology to diagnose HIV earlier: how often do patients have blood tests in the years prior to diagnosis? K Corbett 1 , S Mann 1 , J Williams 2 and D Chadwick 2 1 Newcastle Medical School, UK, 2 James Cook University Hospital, Middlesbrough, UK Background: As significant proportion of people living with HIV remain undiagnosed, and studies suggest many patients who presented late had missed opportunities for testing in the years prior to diagnosis. One method of potentially testing such patients earlier is using software applications embedded in Order-Comms systems to identify patients at higher risk of HIV: when such patients attend clinics, surgeries or hospitals, the application prompts clinicians to add HIV tests to other tests ordered. However such applications will only be effective if patients with undiagnosed HIV attend medical facilities and undergo blood tests. This project aimed to determine if this was the case for a stable and local population presenting with HIV to a clinic in northern England. Methods: All new diagnoses of HIV presenting to our clinic (2012-2016) were reviewed. Patients who'd moved to the area within the last 5 years were excluded. Episodes of engagement with care resulting in blood tests were assessed within the WebICE (Order-Comm) system >3 months and up to 5 years before diagnosis. Reasons for ordering blood tests were reviewed to determine if indicator conditions were potentially present, and (in a subgroup with evaluable results) whether neutro/lymphopaenia, thrombocytopaenia or raised globulin were present. Results: 42 patients were reviewed (median age 44, median CD4 count at diagnosis 281, 90% male, 60% MSM). Overall 80% had blood tests ordered up to 5 years before diagnosis, 24% had a clear indicator condition and there was a median 1 year (per patient) when blood tests were done in the previous 5 years. Of these episode 65% occurred in primary care, 26% in hospital clinics and 9% in A&E or hospital inpatient episodes. In the late presenting group (CD4<350, n=25, median CD4 91) 84% had prior blood tests, there were a median of 2 years when blood tests were done and 38% had indicator conditions. In the subgroup analysed, 22/33 (67%) had blood dyscrasias or raised globulin (21/26, 81%, in the late presenters). Conclusion: A high proportion of patients with new diagnoses of HIV have had blood tests in the 5 years prior to diagnosis, with a significant proportion of the tests indicating blood dyscrasias or raised globulin. Technologies designed to prompt HIV testing using algorithms to detect previous abnormal blood tests amongst other risk factors, when other blood tests are ordered, are likely to be effective in enabling earlier diagnosis. HIV stigma remains a barrier to testing, treatment adherence, and is associated with sexual risk behaviours. We compare stigma experienced between heterosexual men and MSM, and investigate the influence of MSM engaging in chemsex has on HIV stigma. Methods: The People Living with HIV Stigma Survey 2015 was co-designed by people living with HIV and an advisory group of national experts. People were recruited from over 120 cross sector community organisations and 47 NHS HIV clinics to complete an online survey about their experience of living with HIV. Responses were anonymised, stored securely, and analysed with engagement from community members. Results: 1,162 men completed the survey, 969 (83%) identified as MSM, 243 (25%) of which reported engaging in chemsex in the past 12 months. 82% of MSM were white British or Irish compared to 32% of heterosexual men. MSM were less likely to report being in a relationship than heterosexual men (50% and 69% respectively). A multivariable analysis of social discrimination variables found that MSM were over twice as likely to report sexual rejection in the past 12 months compared to heterosexual men ). 36% of MSM reported sexual rejection in the past 12 months compared to 14% of heterosexual men. There was no difference in attributing this rejection to their HIV status, but was high for both groups (MSM Mean=70.2 SE=2.02; heterosexual men M = 74.5 SE=7.47). MSM who engaged in chemsex in the past 12 months were more likely to report sexual rejection compared to MSM who did not report engaging in chemsex (AOR 1.71 [95%CI 1.17-2.52]). Conclusion: MSM living with HIV in the UK experienced greater stigma and discrimination in terms of sexual rejection compared to heterosexual men, and this effect was exaggerated for MSM who had engaged in chemsex. Where sexual discrimination had been experienced, all groups were likely to attribute this rejection to their HIV status.

ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 P133 A new service for people living with HIV with mental health problems D Bradshaw 1 and A Bennett 2 1 Brighton and Sussex University Hospitals NHS Trust, UK, 2 Sussex Partnership NHS Foundation Trust, UK Background: Mental health problems (MH(P)) are highly prevalent amongst people living with HIV (PLWH). We audited access to MH services according to British Psychological Society guidelines and responded to the findings. Methods: 1. A retrospective notes review and phone consultations were undertaken for PLWH recently discharged from hospital. 2. A new service was established in response to findings and characteristics of service users are described for an 8 month period. Statistical analysis of factors associated with MHP was with Chi-squared or Fisher's tests. Results: 1. For n=73, 86% (63) were male, median age was 43 (29-66) years; HIV VL was undetectable for 78% (57); 26% (19) reported alcohol excess, 10% (7) recreational and 4% (3) injection drug use; 32% (23) reported current MHP and 38% (28) previous MHP. Recreational drug use was associated with current MHP (p=0.01). For 33 individuals with current and/or past MHP, 45% (15) participated in phone interviews, with 11 deemed unsuitable for a call and 7 uncontactable; 40% (6) felt health care professionals (HCP) had not given them sufficient opportunity to discuss their MHP and 40% (6) experienced stigma. 2. A weekly pilot joint HIV-psychiatry clinic was set up, with 11 patients discussed virtually, and 36 face to face appointments involving 14 patients; 14/14 were male; for 12/14 (86%), VL was undetectable. Diagnoses were: depressive (n=6) and/or anxiety disorders (5), personality disorder/trait (6) and other (4). A new psychiatric drug was started (4) or dose changed (1); for 8 individuals, an onward referral was made to psychological or other talking therapies. Median waiting time for an appointment was 35 days versus 60 days for conventional MH services. Seventy-one per cent (n=10) individuals completed feedback questionnaires; 9 were very satisfied or satisfied with the nature and timeliness of the information they received prior to attending, and that the appointment was beneficial for their current problem; 10 were very satisfied or satisfied with the appointment location. Conclusions: PLWH who were recent inpatients had a high prevalence of MHP; a significant minority felt they had not had sufficient opportunities to discuss their MHP. A new service led to reduced waiting times and a corresponding high level of satisfaction. HIV centres should consider auditing provision of MH services to PLWH and expanding access where indicated.

A review of patients who fail to disclose their HIV status to the GP: is care compromised? D Friday, R Meade, S Botchey and G Brook London Northwest Healthcare NHS Trust, UK Background: As more and more HIV positive people are living long and healthy lives, it is important they have access to general practitioners (GPs) who have experience in treating a wide range of day to day health conditions. BHIVA recommend that patients are encouraged to register with a GP, if not already registered, and that the HIV service regularly communicates with the GP about their patient, including the creation of a care plan if appropriate. The objective of this review was to determine how many patients within our HIV service fail to disclose their status to the GP and to explore the reasons. Method: A retrospective review of the electronic patient records (EPR) was conducted and all patients whose clinic letters were not sent to the GP and those where the GP was not aware of status were selected. The following were recorded: demographics, duration of diagnosis, CD4 count, viral load, antiretroviral therapy and reasons for failing to disclose. Results: Overall, of the 1000 patients across two sites, only 32 patients failed to disclose to their GP. 19 (59%) males and 13 (40%) females.17 (53%) heterosexual, 13 (40%) homosexual and 3 (9%) bisexual. The majority 13 (30%) were between ages 45-55 with origins from Sub-Saharan Africa. Almost 60% of patients were diagnosed within the last five years, 4 (12%) between 5-10 years and 9 (28%) greater than 10 years. 29 (90%) were well established on anti-retrovirals (ARVs) of which 18 (62%) had utilized one to three regimens. The average CD4 count was greater than 400 and viral load fully suppressed. As anticipated most patients were first diagnosed in the GUM clinic, 21 (65%) and the remaining 11 (35%) in other specialities. Only 12 (37%) were registered with a GP at the time of diagnosis. 15 (47%) patients had co-morbidities which included hypertension 2 (13%), diabetes 1 (7%), asthma 1 (7%) and mental health illness 3 (20%), obesity 4 (26%) and others 4 (26%).The reasons for lack of disclosure was not always clearly documented however, anxiety around confidentially, immigration issues and inability to find a suitable GP were commonly cited. Conclusion: Overall the majority of patients disclosed to their GP, however the review highlights the need for further work to encourage all patients to disclose. For patients with mental health issues care is compromised as they struggle with adherence and drug use which can be better managed with at the primary care level.

Enablers and barriers to diet and exercise behaviour change in people living with HIV: a qualitative investigation A Duncan 1 , B Peters 1 , L Goff 2 and C Rivas 3 1 Guy's and St Thomas' Hospital, London, UK, 2 King's College London, UK, 3 University of Southampton, UK Background: People living with HIV (PLWH) may experience particular enablers and barriers to lifestyle change; some have been reported to be HIV-specific. This qualitative investigation aimed to characterise these enablers and barriers. Methods: HIV patients with prediabetes attending urban outpatient clinics were invited to participate in a 6-month diet and exercise intervention. Those who completed, dropped out or declined to take part in the intervention were invited to participate in research interviews. Participants were purposively sampled to ensure maximum diversity. A topic guide was used, however participants were encouraged to speak freely. Interviews were digitally recorded and transcribed. Thematic analysis was conducted by the lead researcher using Framework aided by NVIVO software, and checked by collaborators to ensure rigour. Results: From 55 potential participants 23 consented to be interviewed, 19 who took part in the intervention, and 4 who declined. Analysis of interviews identified the key theme of fear of disclosure of HIV status. Participants felt happy to disclose development of diabetes but not HIV. Those who declined participation or achieved fewer intervention goals exhibited an external health locus of control, blaming diabetes risk on HIV medicines, and believing behaviour change futile. Those who achieved more goals considered prediabetes treatable, finding practical ways to surmount barriers. Enablers included a desire to avoid adding to pill or disease burden, and a strong support network. Deliberate weight loss leading to loss of cultural identity and disclosure of HIV status were significant barriers. Valorisation of overweight was a barrier to some from the African communities. Weight loss presented as a loss of identity for gay men who self-identify as bears (a sub-section of gay men who reject normative idealised lean muscularity, and are more likely to be hairier and heavier). Conclusion: The fear of disclosure of HIV should not be underestimated; it appears to affect desire or ability to change behaviour. It is not known if fear of loss of identity among gay men identifying as bears is specific to those living with HIV. Interventions to treat metabolic conditions in PLWH should take account of enablers and barriers to change, some of which are HIVspecific. Patients with an external health locus of control may benefit from psychology referral.

Experiences of stigma and discrimination among women living with HIV in the UK: findings from the People Living with HIV Stigma Survey UK 2015 and experiences of living with HIV in a variety of settings with a specific focus on the previous year. We examine the lived experiences of women who took part in the survey. Methods: An advisory group of community members and experts help design the survey. People recruited from >120 community organisations and 47 HIV clinics completed an anonymous online survey. Responses stored securely were analysed at PHE with community engagement. Univariate and multivariate analyses were performed. Results: 378 (24%) women took part. Both women and men reported relatively high levels of worry, avoidance and exclusion of social settings in the last year and over half of participants had a low self-image in relation to HIV. Overall fewer women reported rejection by a sexual partner (18% vs 33%, p<0.001). More trans women reported worrying about verbal harassment (50%, 9/18 vs 21%, 74/346) and exclusion from family gatherings (39%, 7/18 vs 17%, 60/342) than other women. Despite similar levels of disclosure levels in primary care, women reported less control over the disclosure of their status (aOR 1.65, CI 1.05, 2.59) and lower levels of support following disclosure (aOR 1.99, CI 1.23, 3.21) compared to men after adjustment for demographics. 53% (8/15) of trans women reported being treated differently to other patients at their GP (53%, 8/15) cf 15% (49/318) of other women; almost half (7/16) reported hearing negative comments from a healthcare worker about their HIV status or people with HIV compared to 17% (54/324) of other women. Conclusion: Women feel less control and support in primary care with regard to disclosure of their HIV and trans women experience disproportionate high levels of discrimination. Interventions to increase sensitivity and support within the healthcare are required.

Experiences of stigma and discrimination in healthcare settings for trans people living with HIV in the UK: findings from the People Living with HIV Stigma Survey UK 2015 M Hibbert 1 , W Crenna-Jennings 2 , L Benton 2 , P Kirwan 1 , I Lut 2 , S Okala 2 , A Wolton 3 , M Ross 3 , M Furegato 1 , D Asboe 4 , K Nambiar 5 , J Roche 3 , C Weerawardhana 6 , A Hudson 2 and V Delpech 1 1 Public Health England, London, UK, 2 Family Planning Association, London, UK, 3 CliniQ CIC, London, UK, 4 Chelsea and Westminster Hospital, London, UK, 5 Brighton and Sussex University Hospitals NHS Trust, UK, 6 Queen's University Belfast, UK Background: Trans is an umbrella term used to refer to people who do not identify with the gender they were assigned at birth (as opposed to cisgender). Research into the experiences of trans people living with HIV is lacking. We compare experiences of the stigma and discrimination in healthcare settings reported by trans people living with HIV in the UK with those of cisgender people. Methods: The People Living with HIV Stigma Survey 2015 was co-designed by people living with HIV and an advisory group of national experts. People were recruited from over 120 cross sector community organisations and 47 NHS HIV clinics to complete an anonymous online survey. Responses were stored securely and analysed with community engagement. Trans and cisgender participants were identified via 2 specific questions on current gender identity and assigned gender at birth. Results: 29 (2%) out of 1,528 participants identified as trans: 18 trans female, 4 trans male, 2 gender queer/non-binary, and 5 other. In the past 12 months, compared with cisgender participants, trans people were significantly more likely to report disclosure of their HIV status without their consent by a health care worker to a health care colleague (38% vs. 16%), or to a member of the public (21% vs. 7%) (p<0.01). Furthermore, in multivariate analyses trans people were significantly more likely to report worrying about being treated differently when seeking health care (48% vs. 30%, AOR 2.61 [95%CI 1.06-6.42]) and report delayed or refused treatment (41% vs 16%, ) in the past year after controlling for other demographic and social factors. In 2015, almost half (45%) of trans people living with HIV had avoided health care when needed, compared with 28% of cisgender people living with HIV. Conclusion: Despite excellent health outcomes, people living with HIV in the UK, and especially trans people, continue to report high levels of stigma and discrimination in the health care setting. Avoidance of health care due to HIV status has potential leading consequences on health and wellbeing. These findings call for increased trans-specific awareness and education within healthcare settings and greater support of trans people living with HIV who seek health care through the NHS.

Investigating the intersection of substance use and high-risk sexual behaviours, and their associations with mental health, in people living with HIV E Pool 1 , J Vera 1 , A Winston 2 , E Bagkeris 3 , C Sabin 3 , P Mallon 4 , M Sachikonye 5 , F Post 6 , A Pozniak 7 and M Boffito 7 1 Brighton and Sussex Medical School, UK, 2 Imperial College London, UK, 3 University College London, UK, 4 Univeristy College Dublin School of Medicine, Ireland, 5 UK Community Advisory Board, London, UK, 6 King's College London, UK, 7 Chelsea and Westminster Hospital, London, UK Background: A high prevalence of smoking, alcohol and recreational drug use is reported in people living with HIV, in addition to higher risk sexual behaviour. We investigated the association between these risk behaviours, and assessed whether the presence of multiple risks is associated with measures of mental health among HIV-positive participants in the POPPY Study. Methods: Substance use was assessed via a detailed patient questionnaire and high-risk sexual behaviour was inferred from a sexually transmitted disease (STD) diagnosis in the last year. Mental health was assessed through 1) patient reported history of mental health conditions; 2) any current depressive symptoms (Patient Health Questionnaire [PHQ-9] ≥5); and 3) current significant depressive symptoms (Center for Epidemiologic Studies Depression [CES-D] ≥16). Associations between the presence of multiple risk behaviours and measures of mental health in men having sex with men (MSM) were investigated via logistic regression after adjustment for demographic factors. Results: Of the 1072 HIV-positive POPPY participants (85% male, 76% MSM, mean (range) age 52 (20-82) years), 25% were current smokers, 14% reported drinking >21 units alcohol/week, 29% recent (<6 months) drug use and 62% a recent STD; 152 (14%) reported ≥3 of these behaviours and were defined as exhibiting a 'high-risk' phenotype. The prevalence of this phenotype declined with age (odds ratio (OR)/10 years older 0.73 [95%CI 0.61-0.96], p<0.001) but was seen in all age groups. 144/152 with a high-risk phenotype were MSM; after adjustment for age, MSM were 7.1 times more likely to report a high-risk phenotype than heterosexuals ], p<0.001) but no other predictive factors were identified. Among MSM, 320 (39.1%) reported a mental health condition, 320 (39.1%) had PHQ-9 ≥ 5 and 355 (43.4%) had CES-D ≥ 16. MSM reporting a high-risk phenotype had an increased risk of all three measures of mental health status (Table) .

Conclusion: A subgroup of participants reporting multiple risky behaviours was identified, which was strongly associated with being MSM. In MSM, this phenotype was generally associated with all measures of mental health.

Modifying stable antiretroviral therapy: what do patients think?

Lewisham and Greenwich NHS Trust, London, UK Background: The development of newer fixed-dose ART combinations, adjustment to drug pricing by commercial tendering processes and the increasing availability of generic antiretrovirals offer an opportunity to reduce toxicity, decrease pill burden and manage the cost of HIV treatment. Clinicians and patients are comfortable with changes to treatment in response to virological failure or unacceptable side-effects. However, adapting otherwise stable treatment on the basis of cost requires a different type of conversation and may be challenging for clinicians and could provoke patient anxiety. We sought to establish the attitudes towards changing ART in a range of different scenarios amongst stable, virologically-suppressed patients. Methods: A self-completed questionnaire was offered to all stable patients (on ART >6 months, undetectable HIV viral load and no plans for treatment change) over a four week period in December 2016. It elicited the patient's ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 level of satisfaction with current medication and their level of agreement (rated on a 5-point scale with "strongly agree"=5, "strongly disagree"=1) with changes in treatment in several different situations. Results: The questionnaire was completed by 50 patients. 64% of respondents were male and 46% were black-African. 47/50 (94%) agreed or strongly agreed with the statement "I am happy with my current medications" (mean score 4.6). Patients were most amenable to change their medications for a novel medication (score=4.32), to reduce side effects (4.19) and to take fewer tablets (4.07).Patients were more ambivalent to change medication if for a change to a generic form (3.95) and if recommended by a physician (3.98). Patients were more resistant to changing therapy based on cost improvement (3.40) with 48% agreeing/strongly agreeing with this, falling to 38% if the patient was made aware of the magnitude of the saving. Conclusions: Patients were happy with their current medications and were generally resistant to treatment change. Circumstances in which changes were viewed more positively involved those associated with a direct benefit to the individual. Patients were more adverse to changing medications if cost was the primary driver for change and awareness of the size of saving appeared unlikely to influence this. We plan to explore attitudes and knowledge around treatment change and generic therapy in a larger qualitative project. Background: Young people with HIV are a vulnerable group who have distinct needs. HIV may have been diagnosed at a time of huge transition in their lives. A desire to 'fit in' and avoid further stigma may increase the influences of peer pressure and risk taking behaviour. The use of drugs may increase sexual risk taking and compromise ability to adhere to ART. This increases risk of HIV transmission. There is little data about drug use in young adults with HIV. Our aim was to assess the use of recreational drugs among young people with HIV attending a dedicated young adult HIV service, in a large inner city HIV clinic. Methods: A questionnaire was designed and local ethics approval attained. All patients attending the young adult HIV service between June and Dec 2014 were provided with an anonymous questionnaire which they filled in privately and then posted into a secure box. The questionnaires were retrieved at the end of the study and data analysed. Results: 99 young people aged 17-26 completed the survey. Median age 22. 73/99 (74%) were male. 51/99 (52%) MSM, 40/99 (40%) heterosexual, 8/99 (8%) bisexual. 39%, 18% and 57% reported smoking currently, previously and never respectively. Respondents reported using the following drugs regularly: 50/99 cannabis, 31/99 cocaine, 19/99 MDMA, 29/99 Mephedrone, 15/99 Ketamine, 22/99 Viagra, 18/99 GHB/GBL. All drug use was more common among MSM compared with heterosexuals: 38/51 MSM reported regular or occasional drug use compared to 15/40 heterosexuals p<0.005. 5/8 Bisexuals reported drug use. 9/99 reported injecting drugs at least once. Only 8/99 felt their drug use was a problem for them, with 7/99 seeking help for their drug or alcohol problems. 24% reported unprotected sex because they were high on drugs. 66% of respondents were on ART; 16% reported missing ART as a result of drug use, and 12% had missed appointments in the HIV clinic. When asked about drug interactions, only 7% were aware that recreational drugs might interact with their ART. Conclusions: These data show that drug use is common among the young people attending our service, particularly MSM. Drug use lead to unprotected sex and missed ART in some cases, and could be an important factor in onward HIV transmission. Support for young people in using recreational drugs less and more safely, and limiting drug-drug interactions, is key in keeping this vulnerable cohort safe and aware of risk.

The impact of resilience upon experiences of stigma: findings from the People Living with HIV Stigma Survey UK 2015 P Kirwan 1 , L Benton 2 , W Crenna-Jennings 2 , M Hibbert 1 , I Lut 2 , S Okala 1 , L Thorley 3 , D Asboe 4 , J Jeffries 2 , L Stackpool-Moore 6 , C Kunda 3 , R Mbewe 3 , J Morton 3 , M Nelson 4 , I Reeves 5 , M Ross 4 , W Sseruma 4 , G Valiotis 3 , A Wolton 3 , A Hudson 2 and V Delpech 1 1 Public Health England, London, UK, 2 Family Planning Association, London, UK, 3 Stigma Index UK 2015 Advisory Group, London, UK, 4 Chelsea and Westminster Hospital, London, UK, 5 Watipa, London, UK, 6 Homerton University Hospital NHS Foundation Trust, London, UK Background: Psychological resilience is a measure of the ability to appropriately adapt to stress and adversity, with low resilience linked to clinical depression and anxiety. We investigate the usefulness of a validated resilience scale when applied to experiences reported by people living with HIV. Methods: The People Living with HIV Stigma Survey UK 2015 was codesigned by community members and HIV experts. 1,576 people recruited from 120 community organisations and 47 HIV clinics throughout the UK completed an anonymous online survey. Responses were stored securely and analysed at PHE with active community engagement. The validated Connor-Davidson Resilience Scale (CD-RISC 10) was included in the survey. Scores of participants who answered >7/10 questions were calculated and the mean of all completed responses used to impute missing responses. Participants were classified as having low, medium, or high resilience using cluster analyses. Experiences of stigma and discrimination were compared for those with low and high resilience. Results: The majority of 1,568 participants responded positively to resilience questions: 64% often or nearly always were able to adapt to change and 63% to bounce back after hardship [mean resilience score 26.5/40 (SD 8.2)]. 429 (27%) had low, 611 (39%) medium, and 528 (34%) high resilience. In the past year those with low resilience were more likely than those with high resilience to have been diagnosed with depression (71% vs 22%) and experienced social discrimination (verbal/physical abuse and exclusion) (46% vs 23%), anxiety (53% vs 24%) and/or avoided social/sexual experiences (54% vs 32%) (all p<0.001); furthermore, avoidance was more likely to be attributed to their HIV than other factors (34% vs 19%, p=0.001). No significant correlation was observed between resilience and age, gender, sexuality or ethnicity. Thematic analysis of participants' experiences of living with HIV identified that those with low resilience most commonly reported "social isolation" and "negative experiences" whereas those with high resilience focused on "adopting healthier behaviour" and "empowering experiences". Conclusion: A resilience scale may be a non-intrusive way of assessing negative experiences of living with HIV, including stigma and discrimination, and could therefore be used as a screening tool in HIV clinics for referral to counselling, peer support and other support services.

Uncharted territory: a report into the first generation growing older with HIV L Scott, D Laycock and C Blowes Terrence Higgins Trust, London, UK Background: Due to an incredible advancement in treatment over the past 30 years we are now seeing the first group of people growing older with HIV. This research explores what growing older with HIV means for people in the UK. This includes those who have been long term diagnosed and those in the growing cohort of people being diagnosed in their 50s and older. Methods: This project was designed as a peer led piece of research. We recruited 12 peer researchers all of whom were aged 50 or older and living with HIV. The peer team assisted in the design, implementation and interpretation of the research. Participants from across Great Britain were recruited to complete a comprehensive survey, take part in an in-depth interview or group workshop. Results: 307 individuals were included through to analysis, via 246 survey responses, 30 interviews and 6 workshops. Ages ranged from 50 to 83 with a median age of 55, 22% of participants were women. A wide range of experiences, requirements and concerns were observed. Factors such as being ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 diagnosed before effective treatment was available, being aged 50-60 and being a woman were connected with higher levels of self stigma, benefit reliance, lower self-reported wellbeing and greater concern for the future. 58% of survey participants were living on or below the poverty line. 58% of respondents reported moderate to high HIV self stigma, and 82% reported moderate to high levels of loneliness. Future care was a key concern for participants. Survey respondents had on average 3 times more health conditions (in addition to HIV) than the general population of the same age and only 12% have made financial preparations for future care provision. Satisfaction with the quality of care received at HIV clinics was consistently high, although there was frustration that clinics are no longer a one-stop-shop for all health care needs. Quality of care received at GP surgeries was more variable mainly due to inconsistent knowledge around HIV. Conclusion: There is huge diversity in the experiences of this cohort spanning from the beginning of the epidemic though to very recent diagnoses. Many people will need little support as they grow older with HIV. However for others who experience complex health and care needs, poverty, and poor emotional wellbeing, additional services and support is needed. Well equipped and informed primary healthcare and social care sector, supported by third sector organisations will be vital.

Using feminist and participatory methods to explore the experiences of ageing with HIV for women in London J Stevenson 1 , E West 1 , J Smith 1 and P Keogh 2 1 University of Greenwich, London, UK, 2 Open University, Milton Keynes, UK Background: Ageing with HIV is a growing issue, which is only relatively recently gaining the attention of researchers. Much is unknown, around both the clinical and social challenges of negotiating older age with HIV. For women ageing with HIV, there are additional challenges around relative invisibility, a lack of understanding and evidence for gendered needs and experiences and coping with HIV alongside other ageing experiences such as menopause.

Methods: Three participatory, creative workshops were held with women aged over 50 and living with HIV in London. Each workshop was supported and hosted by a third sector organisation, NAZ, Food Chain and AHPN. 18 women participated in total. Each workshop lasted for about two hours. They were all recorded, transcribed and anonymised. In addition to the recordings, creative outputs were collected. The workshop was structured flexibly, with core activities and additional discussion points, used depending on group dynamic and flow of discussion, so each workshop varied slightly. The key creative activity was body mapping, adapted for use as a research technique to support women to explore and share their experiences through creative means, with the intention that this facilitates greater sharing and offers an alternative to discussion, for those participants who prefer it. Results: Isolation emerged as major theme in all the workshops. Participants described loneliness and physical isolation, with a lack of social support, and family and friendship networks as well as lack of access to support services, and described fears of this increasing as they grew older. In addition, participants described the impact of physical challenges of ageing, menopause, managing HIV treatment and side effects, and stigma and discrimination associated with age and HIV separately and in combination. Disclosure and social relationships were particularly challenging. In the body mapping exercise, participants described fear and uncertainty about the future, and dependence on formal sources of support, particularly peer support. Such support was identified as key concern in the context of diminishing resources and cuts to services. Conclusion: The workshops demonstrated that women value the opportunity and space to share their experiences, challenges, fears and hopes around ageing. The use of innovative participatory, creative and assets-based methods including and body-mapping, enabled greater sharing and participation.

A description of the changing needs of inpatient care for HIV patients in the modern antiretroviral therapy era N Smati 1 , S De Saram 2 , M Bower 2 and M Nelson 2 1 Imperial College London, UK, 2 Chelsea and Westminster Hospital, London, UK Aim: To assess the reasons for inpatient admissions at a tertiary HIV care centre and the impact on the need for consultant specialization to deliver optimal care. Methods: A retrospective review of in-patient admissions under the care of the HIV team between January 1st 2016 and December 31st 2016 was carried out. Using electronic patient records, data were collected on reason for admission, length of admission, and level of immunosuppression. All admissions were categorised as related or unrelated to HIV by two independent physicians. Where there was disagreement a third clinician assessed and adjudicated. Results: During the study period there were 255 in-patient episodes (relating to 168 patients). 132 admissions were classified as not HIV-related and 123 as HIV-related. Of the HIV-related admissions, 63 were oncological (46 were AIDS defining malignancies), 43 for opportunistic infections, 10 for investigation of symptoms in patients with CD4 count <350 c/lL, 3 for antiretroviral toxicity, 3 for investigation of symptoms in patients with advanced HIV, and 1 for antiretroviral management. Of the admissions not related to HIV, 38 were for infections,12 for respiratory conditions, 10 for hepatic problems, 9 were oncological, 9 related to substance abuse, 6 were neurological, 5 were renal, 4 were gastrointestinal, 4 were orthopaedic, 4 were haematological, 4 for mental health, 3 were urological, 3 were dermatological, 2 for geriatric related problems, 1 was rheumatologic, 1 was general surgical, 1 for social needs, and 16 for other medical reasons. 

A literature review of the effectiveness of programmes delivering antiretroviral therapy in non-facility based settings in sub-Saharan Africa follow up (LTFU) and mortality, were included. Data was extracted, and qualitative and quantitative analysis were performed. Risk-ratios were calculated and forest plots were created for major clinical outcomes using RStudio to apply a random effects model. Background: Responding to the evolving climate of antiretroviral (ARV) prescribing and cost pressures, the Midlands & East of England ARV Writing Group have devised a prescribing strategy, framed around an innovative visual ARV regimen banding tool. This considers whole regimen costs per month in a clinical context, whilst remaining commercially sensitive. NHS England commissioning statements, national guidelines and tender prices were taken into account. Average banding values are; 1a = £240, 1b = £350, 2a = £445, 2b = £495, 3a = £505, 3b = £615, 4 = £870. As band costs increase, greater levels of team/MDT discussion are required. We look to ascertain the real world feasibility of this regional strategy. Methods: The new tool went live on 01/09/16, and the timeframe we observed was from 01/09/16-30/11/16. Centres submitted data captured in the regional audit form within this timeframe. The anonymised data was collated and analysed. Results: 17 centres provided data, (56%, West Mids, 35%, East Mids, & 9%, East of England), giving 88 datasets. 65% were male, 57% had CD4 counts ≤350 cells/mm 3 , and 37% had HIV viral loads of >100,000 c/ml. The regional estimated cost for a regimen per month was £476. The regional banding use and the percentage of the total expense each band represents can be seen below. *1 data set excluded. The prescribing strategy was correctly implemented in 80% of cases. The most popular band was 2a. Although band 4 regimens only made up 5% of cases, they accounted for 8.4% of the total expense.

Overall 37% of patients were started on a band 3 or 4 regimen, this rises to 50% when reviewing the group which did not follow the strategy. It was observed that 41% of all regimens were single tablets.

Conclusion: Centres contributing data demonstrated high levels of adherence to the regional strategy. The data provides a useful baseline for future analysis.

The ARV banding tool is a simple method to allow clinicians to view data in the same format as they prescribe. Stratifying this further into cost bands allows for comparison of similar regimens with significantly different prices.

This regional strategy is a feasible and flexible way to translate prescribing initiatives into a format that is clinically relevant, whilst remaining costeffective and responsive to changes in drug pricing.

Attitudes to shared electronic patient record systems in a Surrey HIV clinic D Atefi 1 and SY Chan 2 1 Homerton Sexual Health Services, London, UK, 2 Ashford and St Peter's Hospitals, Surrey, UK Background: Electronic patient record (EPR) systems are becoming commonplace in many parts of the NHS. This transition prompts us to consider whether shared EPRs between GUM/HIV services and other NHS services are acceptable to our patients and staff. Methods: We conducted a 10-question paper survey of patients attending a routine HIV clinic appointment between June and September 2016. Furthermore, we conducted an electronic staff survey concurrently. Results: We received 51 patient and 50 staff responses to our surveys. A majority of patients (67%) were accepting of their GP having access to their HIV clinic notes, while just less than half (47%) agreed with a shared EPR system between GPs, GUM/HIV and other hospital services. 56% of staff surveyed felt that healthcare providers outside the GUM/HIV department should have access to these notes. Many concerns around shared EPRs stemmed from fear of stigmatisation, although confidentiality, effects on the patient-physician relationship and implications for travel were also cited. The staff responding recognised many benefits of shared EPRs as well as the potential limitations and disadvantages. Conclusion: We have shown that there is considerable acceptance for the principal of sharing EPRs between HIV and primary care services. This study shows that sharing of data with secondary/tertiary services is less readily accepted, but strategies to mitigate concerns regarding this may be possible. investigate the prevalence of abnormal results of baseline investigations in patients attending an HIV outpatient service. Methods: All infected patients attending the HIV department between 1st January and 20th October 2016 were included in the study. The cohort included HIV infected patients transferring their care to the department and attending the clinic for the first time during the study period. The results of the first measurements of haematology, renal, liver and cholesterol/lipid profiles of those patients were reviewed. We used ACTG grading to identify abnormal results.

Results: A total of 134 patients attended the clinic for the first time during the study interval. This included 123 newly diagnosed HIV infected patients and 11 patients who transferred their HIV care to our centre. Of the newly diagnosed patients, 17 (14%) had an avidity index consistent with recent HIV infection. At the first investigation, six patients had grade 3 renal failure. In three cases, renal function normalised to an e GFR >90 ml/min within four weeks of starting combination antiretroviral treatment (cART). Two patients had hypertension. Grade 1 transaminitis was detected in 17 (12.7%) patients. Of those, hepatitis C infection and non-alcoholic fatty liver disease were each diagnosed in four patents. Total cholesterol to HDL ratio of equal to or more than 5 was detected in 24 (18%) patients. Haemoglobin electrophoresis of patients with ethnicities other than Northern European identified sickle cell trait and G6PD deficiency in six and four patients respectively. Conclusion: The majority of newly diagnosed patients had a normal screening for general physiology. Baseline investigations provide a good measurement of patients' general physiology that may be beneficial in longitudinal observations.

Capacity building for senior clinicians improves health care in a resource-poor setting P Olupot-Olupot 1 and J Meadway 2 1 Busitema University, Mbale, Uganda, 2 Medicines for Muheza, London, UK Background: In 2005, a UK physician undertook a survey of HIV services in the Eastern Region of Uganda and became aware of a lack of appropriate postgraduate training in HIV for senior clinicians, and that they were not supported in carrying out training with other grades of health workers. The clinical resources which were available, including antiretroviral therapy, were not being used effectively because of this, and some patients were denied treatment which was available in their clinic because of lack of knowledge amongst the clinical staff. Method: In 2006 a small UK charity funded a postgraduate course for senior clinicians with update sessions in HIV, developed entirely in partnership with local clinicians. From this an annual conference developed, which has occurred each year, the 12th is being planned for 2017. Participants had presentations lectures and workshops on clinical HIV updates, and improving skills in modern adult education techniques, making presentations, audit and research. Increasingly they studied area of their own work and made presentations about them during the conference. Local guidelines were developed during conference sessions. Participants also could apply for funding to undertake a small research project or audit, or to take a training session to staff from a remote area with no educational facilities. Results: In the last 11 years the following were achieved:

• 400 individual encounters with senior clinicians. • 9 annual conferences for senior nurses • Local clinicians rsn 4 or more large mentorship workshops annually • Health care in rural areas improved through training workshops for staff • Each senior clinician made an HIV presentation at their work place • Clinicians have conducted four HIV studies for publication. • Before the national guidelines or WHO guidelines were rolled out for eMTCT, local guidelines were in place and implemented • Guidelines on Post Exposure Prophylaxis developed locally were used in planning National Guidelines.

• Clinicians set up HIV clinics in three rural settings • Overall care of HIV patients has improved.

Conclusions: In a resource-limited setting, empowering local clinicians through regular training brought about important changes at every level of health care.

Evaluation of BeYou+ an mHealth application to support self-management strategies for people living with HIV D Brown 1 , S Waugh 2 , A Bussone 2 and S Stumpf 2 1 Chelsea and Westminster Hospital NHS Foundation Trust, London, UK, 2 Centre for Human Computer Interaction Design, University of London, UK Background: BeYou+ is a newly developed app designed to provide users with reliable information about their body, mind and life. It is the only known mobile health (mHealth) app to support self-management strategies for people living with HIV. The app gives users the ability to set goals, achieve rewards, input health information and set calendar reminders. Methods: Between July and December 2016, usability and usefulness of BeYou+ (version1.1.1) was evaluated by; (a) expert heuristic evaluation (b) expert review against existing research publications relating to systems designed for use by people living with HIV (c) feedback from potential users (d) feedback from current users and (e) end-user evaluators who had not used or downloaded BeYou+. Feedback from users was obtained via anonymous online questionnaire, with end-user evaluation including BeYou+ screenshots and omitting questions on self-management, quality of life and well-being. Participants were recruited online via social media platforms or push notifications within BeYou+ app. One interview was conducted for more indepth understanding of perspectives. Results: Total 28 recommendations were made from expert reviews. Overall the app has good usability. The app design could be improved even more by attending to issues in structuring information, consistency and clearer labelling. Informational content is perceived as useful but the added value of having this information on a paid-for app needs clarification. Tracking lab results is appreciated and extending this to other health data eg: symptoms is suggested. Medication adherence and potential interactions is of great importance to respondents and this aspect could be improved in the app. While setting goals is important, users wanted more flexibility in the frequency of goals and how they are notified. Conclusion: BeYou+ has been designed very well and presents a few usability issues relating to structuring of information, consistency and clearer labelling that could be addressed quickly in an updated version. BeYou+ is considered useful by people living with HIV, but there are several avenues for improvement including; clarifying added value, expanding health information tracking, medication adherence support and more flexibility in goal frequency & notification.

Exploring online peer support for people living with HIV A Sparrowhawk and T Lange Terrence Higgins Trust, London, UK Background: We live in a digital age and increasingly live our lives online or via digital devices. We report on why people with HIV access online peer support and what outcomes can be achieved. Methods: Active users of an online peer-led forum were invited to take part in a small-scale survey regarding online peer support. Data collection was undertaken 24 November to 12 December 2016. Secondary service data was reviewed for the period 1 April to 30 September 2016. Results: Sample size was 31. 80% of respondents advised they joined the service to talk to other people with HIV, 70% to find out information about HIV. Two respondents advised there were no local services in their area. Four said services in their area did not meet their needs. Regarding access to online peer support and volunteers with lived experience of HIV: 69% agreed/strongly agreed it increased their mental wellbeing compared to 55% in relation to physical wellbeing; 76% agreed/strongly agreed it increased their confidence to self-manage their diagnosis; 76% agreed/strongly agreed it reduced their need to contact their GP or health care workers in a primary care setting; 79% agreed/strongly agreed it increased their confidence in having discussions with their consultant or specialist nurse; 83% agreed/ strongly agreed it increased their knowledge of their own HIV treatment and care. Whilst 83% agreed/strongly agreed it increased their confidence in talking about HIV to other people with the condition, only 66% agreed/ strongly agreed it reduced their feelings of social isolation, 57% that it reduced their feelings of loneliness and 59% that it increased my sense of self-worth. Analysis found respondents 50 and over (n=10) and those living ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 in a rural location (n=7) reported less positive outcomes. Those diagnosed in 2016 (n=10) and gay and bisexual men (n=19) reported more positive outcomes. During the six month period from April 2016, 311 hours of support were delivered by volunteers resulting in 438 interventions, the chief categories being: Living with HIV (137); Recently diagnosed (109); Treatment basic information (69); Emotional support (56) and Accessing services (15). Conclusion: Despite the absence of face-to-face contact and with challenges of digital communication, users reported good outcomes in this small-scale study. Online peer support provides people with confidence to self-manage their HIV and increases confidence in their own knowledge of the condition.

Frequent stable attenders: is HARS missing the true complexity of stable patients?

A Patel, S George, M Roche, D Churchill, E Nixon and Y Gilleece Brighton and Sussex University Hospitals NHS Trust, UK Background: HARS, introduced in 2013 categorises HIV patients into 3 groups: Complex (c 10%), New (c10%) and Stable (c80%). Collected in real time HARS may be used as an HIV commissioning tool therefore it is important to assess its accuracy. When first piloted concerns were raised that HARS subcategories were too specific & would not capture all the complexities of all HIV attendances. BHIVA guidelines recommend that Stable patients are followed up every 6 months. We reviewed our appointment activity & identified many of our Stable patients were seen more frequently therefore we performed a pilot study to investigate the reasons for increased attendance within the Stable patient category. up standards of care and helps achieve better outcomes for patients. We are a research-active department and have offered opportunities to participate in a range of interventional and observational studies over the last ten years with a high level of engagement from our patients. We sought to judge the current level of interest in research amongst our clinic cohort and to determine the types of research our patients would be happy to participate in to inform our future strategy. Methods: A self-administered questionnaire was offered to all individuals attending for care over a four-week period in August 2016. This consisted of 5 questions designed to determine our patients' interest in different types of research and their preferences for accessing information about research opportunities. Results: 95 patients completed this questionnaire of whom 51% were female, 65% Black-African and with a median age of 46 years. 97% of patients were currently on ART. 17% had previously taken part in a clinical trial and 85% of all patients agreed to be contacted by the clinic should a suitable research opportunity arise. 44% of patients were interested in trials that involved changing treatment to a new drug, and 39% would consider changing to a novel or more experimental new type of treatment, such as an injected therapy. 54% of patients were interested in trials involving simply taking an extra blood test, or using blood results/ routine health information for research. In general, men appeared more inclined to participate in trials. There did not appear to be any significant difference in attitudes towards research participation with regards to the age or ethnicity of the patients. Only 21% reported using the clinic website as a source of information. Conclusion: Our snapshot demonstrated a high level of interest in clinical research with surprising support for participation in drug trials, although observational studies and qualitative research also attracted support. We continue to collect this information and it will help inform our future choice of studies to open and allow us to develop a database of patients who would consider clinical trial participation. We are currently evaluating the use of SMS to direct patients to the research page of our website as a means of improving recruitment to studies.

Healthcare professionals questionnaire evaluation of an education intervention to strengthen their HIV testing in high HIV prevalence general practices in a city within the southwest of England C Davies 1 , J Kesten 1 , J Horwood 1 , M May 1 , M Gompels 2 , M Crofts 3 , B Coleman 4 and A Billing 4 1 University of Bristol, UK, 2 Southmead Hospital, Bristol, UK, 3 Central Health Clinic, Bristol, UK, 4 Bristol City Council, UK Background: To encourage appropriate HIV testing, a city council commissioned an education intervention in GP-practices with high HIV prevalence within a city in Southwest England. We report on a questionnaire administered to obtain feedback on the appropriateness and usefulness of the training from participant healthcare professionals' (HCPs). Methods: Education sessions (~1-hour) based on the MEDFASH 'HIV testing in practice' online educational tool were delivered as a stepped-wedge randomised controlled trial in 19 GP-practices with a high HIV practice population prevalence (>2/1000). Feedback on the training was via paperbased evaluation questionnaires completed immediately after the training. Mean scores for seven statements were calculated using a 4 point scale (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree). Results: Training sessions were attended by 169 HCPs of whom 93 were GPs, 53 nurses and 23 'others' (e.g. practice manager). 127 (75%) of evaluation questionnaires were completed. Mean scores were above 3 for the following statements: 'I can apply the information gained from the training in my practice setting 'and 'The trainer actively involved me in the learning process' scored the highest (mean score 3.7). Statements that participants were 'more aware of the BHIVA and NICE guidelines on HIV testing' scored the lowest (mean score 3.4). Three statements 'The training met my professional educational needs' and 'As a result of the training I feel more confident in my ability to discuss HIV testing with a patient' and 'More confident in my ability to conduct HIV testing' all received a mean score of 3.6. When participants were asked: What do you feel were the strengths of the training? Examples of free-text responses included: "Interactive", summarised risk factors, who to test, how to refer" and "Raising awareness, information about prevalence and presenting symptoms to be aware of". When asked: Would you do anything differently in your practice setting as a result of this training? Responses included "Yes offer testing to more patients, be more aware of those needing testing" and "Yes more likely to offer as part of routine tests". Methods: An online survey was undertaken by 173 people living with HIV (plhiv) from across England respondents were predominantly gay men, ages ranged from 26 to 72 years old, with a median of 15 years of living with HIV. A focus group was held at Positively UK in London with 13 participants; 10 women and three men, all aged over 50. Results: Communication between GPs and HIV Clinics: In our 2010 report GPs and HIV clinicians identified communication as unsatisfactory. In 2016 75% of plhiv stated the HIV clinic communicated with their GP, but only 35% that the GP communicated with their HIV clinic. Clinical Governance: In 2010 we found "Many patients currently do not have confidence in GP's knowledge of HIV". In 2016 41% stated their GP was able to manage their health and 38% that the GP had a good understanding of HIV issues. Often patients did not know what was HIV related and what was not, nor 'where to draw the line' leading to confusion as to who should manage aspects of their care. Confidentiality: Today, 75% of respondents felt their information was held confidentially by their GP. This is an improvement from 2010 when perceptions and fear of confidentiality breaches were common amongst plhiv. Sexual Health: Only 45% of survey respondents perceived their GP as being comfortable talking about sexual health. This has implications as to how sexual health is managed for plhiv in primary care and also poses a greater risk for early identification, diagnosis and treatment. Models of Care: In 2010 the majority of plhiv wanted a GP situated within the HIV clinic and this was mirrored in the 2016 study, with a smaller cohort wanting to access their GP locally. However, the over-riding issue for all was one of knowledge and education of GPs. Conclusion: In the six years between studies there has been some progress in terms of how GPs support plhiv notably in managing confidentiality. However, because of poor communication and knowledge the burden is on the patient to manage their care and ensure all aspects are joined up. Much work is still needed to improve care for people living with HIV and promote supported self-management for all.

HIV testing practices in local genitourinary cancer services: a quality improvement project evaluation current practices throughout Cheshire and Merseyside regarding offering HIV test when early neoplastic lesions are diagnosed. We used a nonvalidated questionnaire via telephone interview with nursing staff offering colposcopy services within the region, the gynaecology specialist nurses and the tertiary cancer centre. These consisted of average five minute discussions with colposcopy nurse specialists at each centre, and the gynaecology and colorectal cancer nurse specialists to clarify whether they were testing for HIV routinely, whether they were offering tests at all, and whether they were aware of any guidelines regarding this. Results: We surveyed 10 hospitals across the region including the cancer centre.

CIN 0/8 (0%) VIN 0/8 (0%) AIN 0/8 (0%) None of the hospitals surveyed currently offer HIV testing to new CIN, VIN or AIN diagnoses. One hospital reported that they were aware of the guidance for CIN and VIN and were considering changing their pathways to reflect this. Conclusions and further directions: Despite guidance from BHIVA, no local service routinely offers HIV testing to individuals with a new squamous genital neoplastic diagnosis. Only one hospital within the region was aware of the BHIVA guidelines. Our actions going forward from this evaluation will include exploration of perceived barriers and education of departments locally and setting up pathways for referral. We aim to develop a patient information leaflet to support and encourage both patients and staff.

Improving HIV care in a large prison cluster S Kegg and J Clarke Lewisham and Greenwich NHS Trust, London, UK Background: We have provided a comprehensive in-reach service for HIV to a large prison cluster since 2015 having previously provided a similar service 2002-2011. We highlight some changes in the prison HIV population and describe the improvements we have made to their management. Methods: We obtained information from the prison healthcare electronic patient record (EPR) system on HIV positive prisoners seen in our service between April 2015 and December 2016. Results: Our previous experience (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) involved a relatively small heterosexual population with modest levels of IVDU. Between 2011 and 2015 patients were transported them to their previous treating centres for HIV care with some ad hoc care given by a sessional HIV physician. 40% were on ART and 70% had been seen in an HIV service in the preceding six months (generally prior to detention). 40% had some information regarding their HIV care on the prison healthcare EPR and the majority had experienced treatment interruptions. To date we have provided care to 93 HIV+ people. 4 individuals were diagnosed HIV positive whilst in prison. The majority of patients are held in the category "B" prison with smaller numbers in the category "A" prison and YOI. 37% are MSM and 29% are known to be HCV co-infected. 25 have been in prison more than once in the last 18 months. In the MSM, 65% of offending behaviour is associated with drug misuse. 74% of patients are on ART and of those 65% have an undetectable VL. 53% reported unscheduled treatment interruptions, usually around the time of coming into prison. 7 patients have refused or opted to defer treatment. We have obtained clinical summaries for 44 patients and have made this available on EPR to facilitate the care of prisoners who move within the prison system. All patients who have left prison have done so with a supply of ART and we identified services for ongoing care in the majority. Conclusion: The number of HIV positive prisoners has increased and a significant number are MSM with offending behaviour associated with drug use. The majority of patients were aware of their HIV status prior to arrival in prison. We have improved prisoner engagement with HIV care and uptake of ART and have made a number of interventions to minimise the risk of unscheduled treatment interruptions. We have streamlined the care of patients moving between prisons, and their engagement with HIV services on release as a key part of offender resettlement.

Intervention to improve the management of hepatitis C infection in a sexual health clinic All patients were seen by the hepatologists within 3 months of diagnoses and offered treatment.

The implementation of the clinic proforma improved the documentation and management of patients with acute HCV infection. Completion of the PHE notification form and partner notification in HIV negative individuals were identified as areas for improvement. We have now implemented this proforma in our electronic patient records. Timely management of these patients can improve the outcome and prevent onward transmission.

Peer mentoring: the impact of Positively UK's Project 100 training programme J Morris, A Anderson, G Brough and M Thompson Positively UK, London, UK Background: This review highlights the outcomes from Positively UK's Project 100 Peer Mentor training programme. The project aims to train 1,000 people across the UK, providing 100% coverage for peer mentoring in HIV services and clinical settings. All peer mentors are people living with HIV. Training covers skills, safeguarding, treatment and transmission of HIV, action planning and goal setting over three days with participants then able to complete an NVQ Level 2 in Peer Mentoring. The evaluation has taken place to demonstrate the impact of training (and providing support) for mentors. Methods: The data covers 9 training sessions; 5 London-based and 4 outside of London, over 6 months. The data collection uses a 10-point Likert scale. The aim was to identify the effectiveness of the training delivery, and the potential outcomes for individuals who will be moving forward into Peer Mentoring. This ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 cohort contains 85 individual participants; 53 males and 32 females. The age range is from 21 to 72 years of age, with an almost even split between heterosexual and gay/MSM/lesbian. All participants completed a form containing 8 questions around various aspects of peer mentoringpretraining and post-training. Q1 -Knowledge of HIV and Related Issues; Q2 -Understanding of How to Use Wellbeing Measurement; Q3 -Ability to Use Action Planning and Problem Solving; Q4 -Ability to Use Active Listening; Q5 -Understanding of Own Attitudes, Values; Q6 -Understanding Stages of the Mentoring Relationship; Q7 -Understanding of Boundaries, Policies and Confidentiality; Q8 -Knowledge of When to Refer On in a Mentoring Relationship Results: The data has shown increases in all eight areas. The biggest increase (3.62 points) in an area directly applicable to peer mentoring was the 'understanding of Boundaries, Policies and Confidentiality in the role'. With the 'Ability to use Action Planning and Problem Solving' increasing by 2.47 points from pre-training to post-training. The increase of all measured areas shows a favourable set of outcomes from the training itself.

Qualitative evaluation of an education intervention for healthcare professionals on appropriate HIV testing in higher prevalence general practices in a city in the southwest of England J Kesten 1 , C Davies 1 , J Horwood 1 , M May 1 , M Gompels 2 , A Billing 3 , B Coleman 3 and M Crofts 4 1 University of Bristol, UK, 2 North Bristol NHS Trust, UK, 3 Bristol City Council, UK, 4 University Hospital Bristol, UK Introduction: Approximately 25% of people infected with HIV are undiagnosed. Late diagnosis occurs in up to 50% and has negative consequences for patients, public health and the NHS. To encourage appropriate HIV testing, a City Council commissioned an education intervention in GP-practices. This qualitative study examined healthcare professionals' (HCPs) experiences and perceived impacts of the education intervention on HIV testing. Methods: Education sessions (~1-hour) based on the MEDFASH 'HIV testing in practice' online educational tool were delivered as a stepped-wedge randomised controlled trial in 19 GP-practices with a high HIV practice population prevalence (>2/1000). Semi-structured interviews were conducted with HCPs who attended the training approximately 3-months post-training, and the sexual health clinician that delivered the training. Interviews explored pre-training HIV testing practices, factors influencing testing, views of the training, impact on knowledge, confidence and testing practices. GP-practices were reimbursed £40 per interview. Interviews were audio recorded, transcribed verbatim and analysed thematically. Results: 27 interviews (lasting 30 minutes on average) were conducted across 13 practices with 16 GPs, 10 nurses and the sexual health clinician. Participants appreciated the opportunity to update their HIV knowledge through a tailored, interactive session, delivered by a knowledgeable sexualhealth clinician. Post-training, HCPs increased: awareness of HIV indicator conditions; confidence/self-efficacy to offer HIV tests efficiently; and consideration of HIV tests. Whilst some felt they had increased HIV testing others did not. Continued barriers to testing include perceived lack of opportunity to test and not considering HIV during consultations. To optimise intervention impact, follow-up sessions were recommended. Discussion: The findings suggest the HIV training was experienced positively and improved perceived awareness, confidence, and consideration of HIV testing whilst perceptions of testing rates were mixed. This study highlights that HIV education is perceived as valuable for increasing awareness of HIV testing opportunities but repetition may be needed to sustain its impact.

Re-audit of antiretroviral drug wastage in a teaching hospital's sexual health and infectious diseases clinics B Singh, K Michie, I Wheeler, D Trotman, A Best, A Neary, J Clough, N Beveridge and M Chaponda Royal Liverpool University Hospital, UK Background: A 2013-14 audit in the HIV clinics of a large city centre teaching hospital showed antiretroviral (ARV) drug wastage, in both patients stable on ART, and those who switched to new regimens (BHIVA Conference 2015). We identified strategies to reduce wastage, including: 1) Limiting ART supply at time of starting or switching ART to one month, 2) Limiting prescriptions outside routine clinic visits to one month, 3) Encouraging remaining ARVs to be used before non-urgent regimen switches, 4) Enhanced adherence support by community nurses in poorly adherent patients. We reaudited to assess their impact. Methods: Pharmacy records over an 18-month period were screened for: a) patients stable on one ARV regimen b) patients who had switched therapy. The electronic HIV database was also interrogated. Case notes were reviewed to determine reasons for switch and confirm overprescribing of ARVs. Pharmacy data were used to confirm amount of wastage, and corresponding cost, over a one-year period. Results: A total of 1186 patients were prescribed ARVs in 2015-16. On initial screening, 90 stable patients appeared to have had >3 months excess; on review, 4 had hepatitis B (not HIV) infection, 37 had appropriate total dispensation, and 3 had insufficient data recorded. For 46 overprescribed patients, the annual total wastage was 133 months of ARVs, at a cost of £65,447. Of 334 patients screened, 166 switched therapy. Common reasons were simplification (28%), tolerability (26%) and toxicity (17%), with interactions (7%), failure (7%), and adherence (5%) less frequent. Wastage was demonstrated in 59/156 (38%; 10 cases unclear), totalling £40,569. New ARVs were prescribed for >1 month on 39 occasions (23%). Quantities and costs were calculated by at least two assessors; inter-and intra-observer agreement was 100% when tested on three switch patients. Conclusion: Compared with the previous audit, excess stable ARV prescription remained similar, despite an increase in cohort size, while the wastage at switch decreased significantly. Reduction in quantity of new regimen prescribed may be responsible for reductions in wastage, following the simple clinician feedback interventions. However, significant annual wastage was still observed: £106,016. Subsequently, an electronic prescribing system has been integrated into the HIV database, to support requirement-based prescribing.

Screening HIV patients for cardiovascular disease. Can we coordinate better with primary care?

H Alexander, C Kirby and M Brady King's College Hospital, London, UK Background: BHIVA guidelines recommend screening and monitoring for age related conditions such as cardiovascular health. There is considerable overlap between the recommendations in HIV guidelines and the screening undertaken in primary care. This project aimed to determine whether duplication occurs in the monitoring of the cardiovascular health of our HIV patients and whether our service is achieving BHIVA audit standards. Methods: The GP Quality and Outcomes Framework (QOF) was crossreferenced with BHIVA monitoring guidelines to identify areas recommended in both primary care and HIV settings. We contacted local GPs with HIV patients aged 50+ who are both under our care and registered with them. Data were only collected on patients who had disclosed to their GP and agreed to third party information sharing. A retrospective case note review was conducted from EMIS, the GP electronic database, and our clinical records. Data were collected in three areas: assessment of smoking status and onward referral, blood pressure (BP) monitoring and cardiovascular disease (CVD) risk assessment. We also looked at whether the HIV service accurately recorded co-morbidities and medication.

Supplying, dispensing and collecting HIV medicines in the community. A pilot service V Gordon and D Brawley NHS Grampian, Aberdeen, UK Background: HIV medications supplied and dispensed by community pharmacy are currently exempt from VAT. This saving is essential as HIV cohorts grow. Furthermore in services covering rural areas this can provide improved access to medications especially with newer less toxic regimes requiring less frequent review. Our service covers a large rural area including islands and cares for approximately 400 HIV positive patients. As a significant proportion of patients live in these rural areas, there are often shared care arrangements with primary care and/or tele/videoconferencing. The option of community supply and dispensing of HIV medications was seen as an opportunity to provide more localised, patient centred care. Methods: All 347 patients on treatment were surveyed with 20% opting for community pharmacy. For eligible patients community supply arrangements were put in place with all drug companies & wholesalers. Each nominated pharmacy was contacted and/or visited by HIV pharmacist and provided with a transfer pack containing ordering instructions, regimens, drug stability data, interaction resources and secondary care contact information. Hospital based prescriptions were posted to community pharmacies and the drugs were ordered and dispensed accordingly. Patients were then informed when medications were ready to collect. Results: 56 patients are currently receiving medications from community pharmacies. To date this has not affected clinic attendance or compliance and there have been no requests from patients to return to hospital dispensing. In addition the feedback from community pharmacists has been positive. Conclusion: Community pharmacy supply and dispensing is a relatively simple option to establish and provides increased access to care for patients. Furthermore as this model is used in other chronic conditions, this can be viewed as a forward step in normalising HIV care.

The pneumococcal vaccine in patients living with HIV: knowledge and numbers P Gallogly and M Lynn Guy's and St Thomas' NHS Trust, London, UK Background: Streptococcus pneumoniae infection is a significant cause of pneumonia and invasive pneumococcal disease (IPD). HIV-positive adults are at a 40 times higher risk of infection, with associated greater morbidity and mortality compared to aged-matched HIV-negative adults. BHIVA recommend that all HIV positive adults receive a single dose pneumococcal conjugate vaccine (PCV-13) irrespective of CD4 count, anti-retroviral (ARV) use and viral load (VL), and that those aged >65 years or with other co-morbidities also receive a single dose of pneumococcal polysaccharide vaccine (PPV-23). Locally, these BHIVA recommendations are included in all written HIV correspondence to GPs who, at present, are the main providers of the pneumococcal vaccinations .The aim of this study is to establish current patient knowledge of the vaccination(s) and adherence to BHIVA guidelines as demonstrated by the number of patients confirmed to have been vaccinated. Methods: We conducted a cross-sectional study, using a questionnaire, of 50 out-patients attending HIV clinics over a one week period. Medical history and vaccination status was confirmed using hospital and GP electronic notes. Results: 33 males and 17 females completed the questionnaire; age range 22-56 years. Duration of HIV diagnosis ranged from 6 months to 25 years. 48 patients (96%) were prescribed ARV therapy. Mean CD4 count was 618/uL (range 138-1591/uL). 3 patients had a CD4 of <200/uL. Latest VL levels were: <20copies/ml (37), 20-200copies/ml (4), >200copies/ml (9). 12 patients had a history of an AIDS-defining illness. 46 GPs were aware of patient's HIV ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 diagnosis. 44 patients had other co-morbidities; diabetes mellitus (3); lung disease (1); liver disease (1); previous pneumonia (7); current smoker (22); alcohol history (10). 17 patients (34%) had prior knowledge of the pneumococcal vaccine. 14 patients (28%) were aware that they should be vaccinated. 10 patients reported having had the vaccine. GP records confirmed that a further 2 patients (total 12/50) had been vaccinated. All 12 had had the PCV-13; 2 patients had also received the PPV-23. 2 patients had had their vaccination status clearly documented in hospital HIV electronic notes. 25 patients (50%) had no knowledge of the vaccine and 38 patients (68%) were unvaccinated. Conclusion: The study shows that in this general HIV clinic population a significant number of patients had no knowledge of the pneumococcal vaccine, with the majority of patients remaining unvaccinated and at risk of the increased mortality associated with pneumococcal disease. Further health promotion strategies are needed to improve vaccination awareness in this important patient population. Funding for the pneumococcal vaccination administration in HIV clinics, as opposed to current practice which relies on GP administration, may increase uptake of the vaccination in line with BHIVA recommendations.

What are the benchmark standards to ensure high quality and effectiveness of HIV peer support services?

Positively UK, London, UK Background: There is both a growing demand for peer support from communities living with HIV and recognition within the NHS of the role of peer support in supporting clinical outcomes and improving health and wellbeing. (2014) all identify the role of the Third Sector in providing community led support and addressing the need for people living with HIV to access peer-support to promote well-being, treatment adherence and self-management. Developing evidence based standards of HIV peer support is essential to have a benchmark for the HIV community, health and social care providers and decision makers to ensure consistency in approach and promote good practice in the delivery of peer support. Method: The Standards were developed by a Steering Group of people living with HIV, representatives of NGOs providing peer support and of the British HIV Association, National HIV Nurses Association and Children's HIV Association (CHIVA). Targeted consultation was undertaken with groups of people living with HIV in London and Liverpool, the youth group leaders of the CHIVA Summer Camp, and with individuals from across the sector. From August to September 2016 the Standards were then out for open consultation through e-forums including UK-CAB and NGOs across the UK. Results: A format of the standards was identified that included: title, rationale, competencies and skills needed to achieve the standards, expected outcomesthe change we hope to achieve through the standards, and auditable indicatorsto demonstrate how the standards have been implemented. The standards identified were: 1) Everybody living with HIV should have access to peer support 2) People who provide peer support will be living with HIV and have access to training, support and personal development 3) Peer Support will include robust monitoring, measuring and evaluation processes 4) Children and Young People with HIV will have access to child and youth centred peer-support. Conclusions: The standards will be launched early 2017.

What is the impact of having UK-CAB representatives on guideline writing committees and academic/clinical research study boards L Kwardem 1 , R James 2 and J Shepherd 2 1 ReShape, London, UK, 2 UKCAB, UK Background: HIV community engagement in the health care sector has a long history. The UK Community Advisory Board (UKCAB) is a network of HIV advocates with over 800 members and 120 HIV groups and source for community representatives (CRs). Methods: 14 semi-structured interviews were conducted with multidisciplinary England based clinicians (7F/7M) on their experiences on BHIVA/ NHVNA committees, Trial Steering Groups and Scientific Advisory Boards with HIV CRs. Transcript analysis was done using primary coding of pre-set and emergent codes on clinicians experiences of CR impact. Results: Most frequent cited benefit was lived experience and whole pathway perspectives that CRs brought. Others were non-clinical, advocacy, empathy, patient centeredness, research initiation and direction, developing patient information and other dissemination strategies, community prioritisation, lobbying, studies/guidelines reality check, media management and increased learning for clinicians. All interviewees valued the contribution of CRs on committees and identified their unique impact. The UK-CAB is seen as a valuable formal resource for providing skilled CRs. Funding was the most commonly described challenge for community engagement. Some participants felt that training, mentorship, apprenticeship, induction and shadowing was valuable for all professionals and CRs joining committees. Representativeness of CRs had varied views, some were impressed at CRs ability to bring a range of views from the HIV community, others were uncertain about existing feedback systems and some concerns that viewpoints of some groups was unheard. Observation was that people newly diagnosed may have different needs from long term diagnosed. Concern was expressed about CRs selection process and provision of opportunities for newer and less experienced CRs. A number of innovative and best practice examples of community involvement were identified. Conclusion: CRs were highly valued and seen as effective/impactful by all professionals in this study with benefits to the individual, professionals, organization and the health system. Constant reflection is needed for organizations and community to ensure effective representation. Mechanisms within all stakeholders (UKCAB, BHIVA, NHIVNA, TSCs) are needed to sustain the CR model. There was unanimity that people living with HIV must be directly involved in decision making on service delivery and clinical care that will have a direct impact on their lives P169 Women inspire support and empower to unleash positive potential (WISE UP+): workshop for HIV-positive women in the UK

Background: The WISE UP+ workshops aim to provide advocacy skills to women living with HIV, as well as an opportunity to meet and collectively analyse their current situation and to begin to develop an advocacy strategy. Following the huge success of the first WISE UP+ workshop in 2014 the Sophia Forum ran a second workshop for a new group of advocates, in October 2015. The Sophia Forum engaged Positively UK to help with the design and delivery. Methods: The workshop took place in Manchester over 3 days and was attended by 24 women from different parts of England. Women were selected based on their interest in and desire to participate in advocacy. The group was diverse, with 18 black African women, 3 black women from the Caribbean, 1 Russian and 1 European. The age ranged from 27 to 58. The facilitators were all women living with HIV; one of whom had attended the first workshop as a participant. External speakers were also invited to facilitate specific sessions such as sessions on: 'Power, Control and Women's Resistance' with Imkaan, 'Activism and Direct Action' with Act Up and 'Poetry and Advocacy' with Dorothea Smart. The Sophia Forum has recently published a collection of poetry from this session.

Results: The evaluation of the workshop was overwhelmingly positive. Participants were asked to evaluate each session individually (scoring from poor, satisfactory, good and excellent). Ninety-nine per cent of all the ratings for the sessions were either good or excellent. Conclusions: This second WISE UP+ workshop highlighted once again the importance of women only spaces for women with HIV to reflect on their lives and develop confidence and skills to move into activism. The discussions showed how perceived stigma prevents people living openly with HIV, they fear family members, friends, employers and employees will respond negatively. This, combined with poverty, isolation, issues with unresolved immigration cases, and lack of skills, still create huge obstacles for women's full participation in advocacy. However, throughout the workshop the women explored the myriad ways they drew strength to effect change in their lives and how this could be drawn on to catalyze wider transformations.

P170 'You're suffering all these things and you keep going backwards and forwards': experiences of the menopause among women living with HIV in the United Kingdom J McGregor-Read 1 , F Pettitt 1 , F Burns 2 , R Gilson 2 , C Sabin 2 , S Tariq 2 and S Petretti 3 1 UK-CAB, London, UK, 2 University College London, UK, 3 Positively UK, London, UK Background: Improvements in survival due to antiretroviral therapy (ART) have led to a shift in the age distribution of people living with HIV, with increasing numbers of women living with HIV (WLHIV) reaching menopausal age. We present results from a qualitative study exploring experiences of the menopause among WLHIV in the UK. Methods: In collaboration with an HIV charity and two peer researchers, we conducted three focus group discussions (FGDs) in 2015 with 24 WLHIV aged 43-62. All FGDs were transcribed verbatim and analysed thematically in NVivo 10.0. This work is part of the PRIME study, a mixed-methods observational study exploring the impact of the menopause on WLHIV's health and wellbeing Results: Women described a lack of prior knowledge, leaving them underprepared for menopausal symptoms. For women born in Sub-Saharan Africa (n=16), this was exacerbated by cultural taboos around discussing menopause, and loss of kinship networks during migration. Menopause in the context of HIV brought particular challenges. Participants were concerned that menopause could be precipitated by HIV-infection or ART, whilst some were reluctant to take further medication such as hormone replacement therapy when already on ART. Common symptoms such as hot flushes, mood changes and poor sleep, sometimes impacted on ability to adhere to ART. Many participants did not recognise their menopausal symptoms, instead attributing them to ART side-effects or HIV. Furthermore, they found themselves "going backwards and forwards" between primary healthcare providers (HCPs) and HIV-physicians when seeking advice and clinical care, often leading to frustrating delays. Participants highlighted the importance of supportive HCPs and accessible information on HIV and the menopause, and the need for ongoing peersupport, many describing their participation in the FGDs, often their first opportunity to discuss menopause with other WLHIV, as "empowering". Conclusion: This is one of the first qualitative studies to explore experiences of the menopause in WLHIV. Participants encountered particular challenges in the recognition and management of the menopause, as a result of also being HIV-positive. Increasing awareness among patients and HCPs, developing HIVspecific patient resources, and peer-support networks may help support WLHIV at this stage in their lives and limit negative impacts on their HIV care.

Do women with HIV/AIDS on antiretroviral therapy have a lower incidence of symptoms associated with menstrual dysfunction? D Hapangama 1 , N Tempest 1 and D Edirisinghe 2 1 University of Liverpool, UK, 2 Royal Liverpool University Hospital, UK Background: Symptoms associated with endometriosis and menstrual disorders are common amongst women of reproductive ages, the pathogenesis of these illnesses is postulated to be due to aberrations in endometrial regeneration, immune response and endometrial stem cells. Highly active antiretroviral therapy (HAART) has been shown to enhance events seen in biological aging of tissues, with illnesses associated with stemcell aging appearing prematurely in HIV/AIDS patients. The specific component of HAART that causes features resembling ageing are thought to be nucleoside reverse transcriptase inhibitors (NRTIs) which have anti-telomerase activity. We have recently shown that high telomerase activity is a feature of endometrial epithelial progenitor cells and endometriosis. Aim: Examine if women on HAART have a lower incidence of symptoms associated with menstrual irregularities or endometriosis. Methods: 100 HIV positive women (group 1) attending the specialist HIV clinic at the Royal Liverpool University Hospital were consented, completed a questionnaire and the attending doctor recorded the patients HIV related history including recent blood test results. 75 non HIV positive patients (group2) were used as controls. Results: Women in group1 were slightly older (38 vs. 33 years, p<0.01); with higher BMI (29 vs. 25, p<0.01); likely to be parous (85% vs. 47% <0.01) and non-Caucasian (84% vs 21%, p<0.01), compared with group2. Mean duration of diagnosis of HIV was 8 years with 4 patients diagnosed with AIDs. Most (82%) of group1 had a CD4 count of > 400, a viral load of < 50 (93%) and a median duration of HAART of 6 years. A similar proportion of women from both groups did not use contraceptives (30% vs 28%) and more women in group1 used condoms (41% vs 24%). Women reported light or normal flow (56% vs 50%) and shorter duration (<7 days) of bleeding more commonly in group1 compared with controls (90% vs 80%). Women in group1 were less likely to rate menstrual pain as moderate to severe compared with controls (39% vs 42%). Conclusion: Our data suggests that women with HIV on NRTIs have decreased incidence of menstrual flow, duration and pain, supporting our hypothesis, possibly due to the (beneficial) side effects of NRTIs on endometrial telomerase activity. Further studies are warranted to examine the effect of NRTIs to treat patients with menstrual problems and endometriosis. NRTIs have a unique advantage over existing treatments, they allow patients to retain fertility.

Does providing holistic sexual and reproductive health (SRH) care in an HIV outpatient setting improve the SRH outcomes for HIV positive women? R Metcalfe, P Anderson, V Smith and F Fargie Brownlee Centre for Infectious Diseases, Glasgow, UK Background: Our urban HIV service provides pre-conception advice, multidisciplinary obstetric/paediatric/HIV care during pregnancy, contraceptive service, including long acting reversible contraception (LARC) and cervical screening. The female cohort are mostly from areas of high deprivation, in which low cervical screening uptake and high unintended pregnancy rates are well recognised. We aim to enable women to safely plan pregnancies, prevent HIV mother to child transmission and prevent cervical cancer, with the enhanced SRH services provided. We sought to evaluate use of the service, assess pregnancy planning, pregnancy outcomes, contraceptive use and cervical screening in these women. Methods : A two year retrospective review of pregnancies (July 14 to Aug 16). A snapshot analysis of contraceptive use via city-wide hospital and sexual health service case note review (Oct 16). The Scottish cervical call/recall system was accessed to assess cervical screening uptake and recent result (Dec 16). Results: 15 pregnancies resulted in termination or spontaneous abortion in 14 women (disclosed to service) and 39 pregnancies to term in 38 women, with a median age of 33 years (cf national average 30.1 years). Prior to conceiving, 12/39 (8%) reported planning a pregnancy and 5/30 (13%) were documented to be using contraception. After conception, 12/39 (31%) were reported as unplanned (cf national average 20%). In 30/39 (77%) pregnancies, the woman was established on antiretrovirals (ARVs) prior to conception, 27/39 (67%) with HIV VL<40 copies/ml. 4/39 (10%) were new diagnoses during pregnancy. 5/39 (13%) were previously diagnosed but not on ARVs. 8/9 achieved VL<40 copies/ml at term. There were no caesarean sections for non-obstetric reasons. Postpartum, 24% were on LARC and 37% using condoms or no contraception. Figure 1 shows overall contraceptive use in the cohort.

ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70 78% had cervical screening in previous 15 months (cf national rate of 69.8%), of which 84.7% had negative result. Conclusion: There is poor uptake of preconception service and few disclosures of pregnancy planning. The unplanned pregnancy rate is high and LARC rates are low (including post partum), despite all contraception offered. Cervical screening uptake is higher than Scottish national average. We plan to increase patients' awareness of the SRH services and conduct qualitative research to determine why women do not avail of the full SRH service currently offered. Hormone replacement therapy (HRT) is beneficial to HIV positive women who are symptomatic and/or with early menopause and may improve bone health. At our centre 40% of HIV positive patients are female and 625 (63%) are aged >45 years. Postmenopausal women may be referred to an HIV medical gynaecology clinic for review and HRT counselling. Aim: To assess the uptake of HRT in HIV positive postmenopausal women, the effectiveness of HRT in treating menopausal symptoms and demographic and HIV characteristics of those with early, premature or natural menopause. Methods: Retrospective case note review of post-menopausal women with HIV attending the medical gynaecology clinic between 1st Jan 2011-31st Dec 2016. Menopause was classified by age at menopause as premature (<40 years), early (40-45 years) or natural (>45) and baseline characteristics and management described. Results: Of the 579 women referred to medical gynaecology, 73 (12%) were postmenopausal (88% black ethnicity, 95% undetectable on treatment, median (IQR) current and nadir CD4 630 (435,780) and 259 (111,396) cells/ll respectively) The age range at menopause was between 36-53 years; 11 (15%) had premature and 15 (21%) early menopause. There was no evidence of a difference between demographic/HIV characteristics between menopause categories (P<0.5 for all). There was a trend to higher parity among those with natural menopause compared to early or premature (median IQR) parity 2 (1,2) vs. 1 (0,2) and 1 (0,1) respectively, p=0.02). 69 women attended; 49 (71%) to discuss menopause management and symptom control, of which 28 (57%) accepted HRT. 23 (82%) were prescribed systemic HRT; 19 (83%) had continuous or sequential oestrogen patch or gel plus micronized progestogen. 11 (58%) required oestrogen up-titration to improve symptoms. 4 experienced side effects (bleeding N=3, mood disturbance N=1). All women had symptomatic relief within 6 months of starting HRT; 4 discontinued due to side effects and anxiety about breast cancer. 24 underwent bone mineral density evaluation, 15 (62.5%) were osteopenic and 2 (8%) had osteoporosis. Conclusion: HRT was acceptable to the majority of women with HIV who were counselled and offered treatment. All women had symptomatic improvement and adverse effects were rare. Dose adjustments were required in the majority patients.

Prevalence of asymptomatic STIs in patients at high risk of HIV acquisition and transmission in a Ugandan clinic setting E Mabonga 1 , L Hamzah 1 , C Gaydos 2 , Y Manabe 2 , A Elbireer 3 , J Kisakye 3 and R Parkes-Ratanshi 4 1 King's College Hospital, London, UK, 2 Johns Hopkins University, Baltimore, USA, 3 Infectious Disease Institute, Kampala, Uganda, 4 University of Cambridge, UK Background: Management of sexually transmitted infections (STIs) in sub-Saharan Africa utilizes syndromic management. Asymptomatic patients who are at high risk of STIs will therefore not be routinely tested. The aim of the study was to establish the prevalence of asymptomatic chlamydia (CT) and gonorrhea (NG) in key populations at increased risk of acquisition or transmission of HIV, and the risk factors for STIs. Materials and Methods: The study was carried out at the Infectious Disease Institute, Mulago Hospital Kampala from March-July 2015. Asymptomatic patients in the following categories were offered STI testing: HIV discordant couples; HIV young adults; HIV pregnant patients and those attending the 'most at risk population clinic'. Patients were not examined and provided urine, self-taken vulval swab or both to test for NG and CT by polymerase chain reaction (PCR) using BD ProbeTec TM .

Results: 412 patients were screened; 273 (66.3%) women; the median age 29 years [IQR 23-39] with median CD4 505 cells/lL [IQR 351-671]; 368 (89.3%) were HIV positive with 339 (92.6%) on antiretrovirals. All STIs diagnosed were in women (17/273, 6.2%); 15 HIV positive and 2 HIV negative. The prevalence of NG was 10 (3.6%) and CT 7 (2.6%). Having an STI was associated with age <25 years OR [95% CI] 4.4 [1.5-12.9]; being employed OR 3.2 [1.1-9.7] and having a partner of unknown HIV status OR 3.2 [1.1-10] compared to an HIV positive partner. Having an STI was not associated with history of a previous STI, condom use or number of partners. 16 (94.1%) patients were treated; 1 at screening as she was a contact and the other 15 following call back. 10 (58.8%) partners reported to have received treatment. Conclusion: There was a significant prevalence of asymptomatic STIs in females <25 years. These patients would have gone undiagnosed using syndromic management. Untreated asymptomatic STIs may facilitate increased HIV transmission. In asymptomatic key HIV positive populations, self-collected NG/CT tests should be further investigated.

Sexual health of people living with HIV R Thomson-Glover, F Alloba, J Ruffle, S Semple and C Bates Royal Liverpool and Broadgreen University Hospital NHS Trust, UK Background: The British HIV Association (BHIVA) issued 'Standards of Care for People Living with HIV' in 2013 which states specific auditable outcomes relating to sexual health. They advise an annual sexual health history and screen, 3-6 monthly syphilis and hepatitis C serology and an annual cervical cytology screen for women. This audit evaluated the performance of an inner city HIV clinic in meeting these targets and compared it to previous audits. Methods: This was a retrospective study of HIV patients attending an appointment in May 2016. Exclusion criteria included recent HIV diagnosis or patient not attending within the preceding year. Sample size was 104, with 42 female and 52 male (20 patients excluded). Information was gathered from clinic letters, case notes and GUM/HIV and AIDS reporting database (HARS). The 5 domains evaluated were: evidence of sexual health history, sexual health screen, syphilis serology, hepatitis C serology and cervical cytology. Evidence of a contraception discussion was evaluated for quality improvement purposes. 

Our results show an overall improvement in meeting the BHIVA standards of care since 2009, in particular with the uptake of syphilis serology (90%). Audit limitations include unavailable case notes, handwriting legibility and lack of documentation. The clinic is moving away from paper notes which will improve outcomes in some of these areas. Changes to our HARS database are being implemented to aid documentation of sexual health history and screening. Uptake of annual cytology has decreased. Since the result of the audit an IT aide-m emoire has been created reminding clinicians to address overdue smears with patients. The low uptake of a recorded contraception discussion (45%) highlights a need for improvement in this area. Contraception discussion could be included in the BHIVA sexual health auditable outcomes.

Should healthcare practitioners discuss parenthood possibilities with HIV-positive MSM? Preliminary findings from the MAIL Study Methods: Qualitative interviews were conducted with 25 HIV-positive MSM across four HIV outpatient clinics. Men were aged 20-45 (mean=33.5), all but two self-identified as gay, and none had children. As part of the interview, patients were asked whether they wanted to become parents in the future, whether they had ever talked about parenthood possibilities with their clinicians, and whether they thought parenthood and the reproductive health should be discussed as part of HIV care. Results: Of the 25 MSM, 11 expressed some parenting desire. Only four patients recalled talking about parenthood possibilities with healthcare practitioners. In each case, the men had been briefly reassured at the time of HIV diagnosis that it was possible for HIV-positive people to become parents, which they saw as both significant and sufficient information. Most men said that they would like, or would have liked, to discuss issues related to parenthood in the context of HIV or to be directed to relevant information sources. In a minority of cases, living with HIV seemed to have a direct impact on the men's parenting intentions. The most frequently given suggestion was to highlight that parenthood was a possibility at the time of HIV diagnosis, with signposting to information sources for those potentially interested. Most men said that they would feel comfortable asking clinic staff about parenthood possibilities, especially if they had specific questions about implications of HIV for biological parenthood. Conclusion: Our findings suggest that a significant number of HIV-positive MSM would like to have children in the future and that the time of HIV diagnosis is especially crucial for the reassurance that it is possible for people living with HIV to become parents. More detailed and reliable information should be available to clinicians so that they are able to direct patients to relevant resources if needed. It is important for healthcare practitioners not to assume that issues related to parenthood and the reproductive health are not relevant to the MSM population.

ª 2017 The Authors HIV Medicine ª 2017 British HIV Association, HIV Medicine, 18 (Suppl. S1), 14-70

Methods: Age-and-sex specific populations were extrapolated from the national cohort of people accessing HIV care between 2004-2013 and adjusted for expected retention and death rates (source: UK civil registration). The expected numbers of new HIV diagnoses by 5-year-age band were based on the previous 10-year-trends and added to the projected population. Results: The actual number of persons in HIV care steadily increased from 41

women) and in 2028, an estimated 112,700 people will access HIV care: 54% (60,500) aged ≥50, (29% 50-59; 18% 60-69 and 6.2% ≥70 yrs). The number of men in HIV care is expected to increase by 53% (55

Conclusion: Management of an aging HIV population with co-morbidities will require effective liaison between HIV, primary care and other healthcare services

Projected age distribution of people in HIV care 1,2 : UK. Year

Results: Data were initially collected for 38 patients

There were high co-morbidity rates: 47% (18/38) were hypertensive and 18% (7/38) were diabetic. 47% (18/38) had ever smoked and 6 (16%) were current smokers. Of these only two had been given cessation advice. Two patients were recorded as being hypertensive by their GP and not by us. 44% (17/38) were on anti-hypertensives and 37% (14/38) were on lipid lowering therapy

General To explore what the significance of an HIV diagnosis might be in the experience of domestic abuse. 2. To explore the impact of disclosure/non-disclosure of HIV and/or domestic abuse on the woman and her family. 3. To explore specific health and social impacts of domestic abuse for WLWH. 4. To identify perceived helpful support strategies for women and to begin to formulate accessible and relevant service responses. Methods: Ethical approval was granted for 10-15 face to face in depth interviews in a clinical setting. All material has been translated into French and Arabic and women who speak these languages could be interviewed with an interpreter. WLWH were recruited from a busy HIV service in the North West of England. Recruitment was purposive, interviews were semi-structured and a narrative approach was taken. Preliminary findings will be presented; in depth analysis of individual interviews including a poly vocal approach and thematic analysis is underway. Results: Fourteen women have been interviewed, each once and no interpreters were required. All interviews were in the hospital setting. All women interviewed were black; 13 were African from 9 different countries. They were aged between 24 and 53 and 11 of the women were mothers. Interviews ranged in length from 30 minutes to two hours. They discussed a diverse experience of domestic abuse. Each individual interview yielded rich data and insight into the subject area. This study presents the experiences of a highly marginalised group who have not been evaluated in this way before. Conclusion:1. Women living with HIV in the UK experience high levels of domestic abuse. 2. The intersectional nature of oppressive factors in the lives of WLWH is significant.3. Immigration is a factor in the lives of all but one woman interviewed. 4. Domestic servitude and trafficking features in the lives of several of the women interviewed. 5. Poverty was an issue for many of the women both in the UK and in Africa.