HIV and AIDS in Bristol

The first case of HIV occurred in Bristol in 1982 not long after the first case in the UK (Brighton). During the first 10 years the problem was seen almost exclusively in white gay men. Very few women were infected. There was no effective treatment and there was a high death rate.

HIV and Aids are not legally notifiable. Nonetheless careful national records are kept In 1984 there were 4 cases in Bristol and in 1985, 5. The number gradually increased and by 1994 a total of 110 cases had been seen although many had died.

HIV services were originally developed in Ham Green Hospital by Stuart Glover. He ran the Infectious Disease Unit at Ham Green Hospital and became the specialist in HIV and Aids in the City in 1992. In 1998 the care of patients with HIV was moved on to the Southmead Hospital site. Later, Dr Mark Gompels, Consultant Immunologist and HIV consultant, was appointed to help manage the service. In 2001 funding was made available for the appointment of an HIV pharmacist.

There has been a major increase in the number of cases of HIV and AIDS. There are now far more affected heterosexuals. Recently an increasing number of black Africans from the sub-Sahara in Africa have been seen mainly political or economic migrants. In Bristol there are now 50-75 new cases a year and four-fifths of these are black Africans. An increasing number of other family members are affected. Approximately equal numbers of males and females are currently being seen. The total number of cases being seen has doubled in the last 2 years and now approximates to 400 in total. Children are looked after by Professor Adam Finn there are probably about 20 children in Bristol with HIV infection. Dr Glover emphasised that HIV infection in gay men is still occurring.

There has been a major increase in the number of cases with pulmonary tuberculosis particularly in black Africans.

The increase in the number of cases of HIV infection has been paralleled by a large increase in the number of people with other sexually transmitted diseases. Thus, the number of cases of new syphilis have increased recently by about 600%. A significant increase in the number of people with clamydia and gonorrhoea has been reported 100 to 150% over the last 2-3 years.

Dr Glover pointed out that because of the huge increase in the number of people with sexually transmitted diseases it has become impossible for the STD clinics to see all patients. This has now become quite a big issue for the speciality of genito-urinary medicine. It seems that an increasing number of people are being seen by their general practitioners or even at NHS walk-in centres. There is clearly a possibility that some cases of HIV infection will not be diagnosed early because the requisite tests have not been applied. This could represent a significant problem for the future. Stuart Glover pointed out that people who attend the STD at the BRI are very thoroughly assessed by experts.

In 1987 AZT was introduced as mono-therapy. This had a short-lived impact mainly because HIV became resistant to medication quite quickly. 1992 saw the development of dual therapy reducing the speed at which the organism became resistant. In 1997 triple therapy was introduced. Three groups of drugs became available. These allowed much better suppression of HIV. Current treatments can be highly effective. For instance, some HIV patients who have continued with therapy as prescribed, are still well, and not showing any evidence of AIDS, 6 years after the commencement of treatment.

Unfortunately, the medication does have side-effects. The most externally obvious effect is a lipodystrophy in which there is loss of fat from the upper part of the body (arms, legs and face) and central deposition of fat on the abdomen particularly. Medication is associated with various abnormalities of lipid metabolism including a high cholesterol level. Many subjects are heavy smokers. For these, and possibly other, reasons there is a substantially increased risk of coronary artery disease in this group of patients. The mechanism by which the drugs produce these side-effects is not entirely clear.

The prevention of AIDS.

A major objective of management is to prevent the development of AIDS. This means monitoring and treating a considerable number of patients with HIV infection who may be symptomless. The key laboratory measures are the CD4 count and the viral count in the blood.

A few years ago there was a considerable decrease in the number of patients who required in-patient care. However the number has increased recently because of the number of Africans who have clinical AIDS. In 1992 there were a total of 27 beds at Ham Green Hospital for people with infectious diseases. There are now 9 beds most of which are occupied by patients with HIV infection. This poses some difficulties because there is no slack in the system. HIV problems have had a major effect on the way in which other major infectious diseases are being managed partly because there is such a pressure on the beds. For the first time AIDS patients are now having to be looked after as "outliers" on general medical wards.

Stuart Glover pointed out that from a clinical point of view patients can be divided into 2 particular groups:

a) Those that he would classify as "sensible" and who can be relied upon to take their medication and to avoid health-damaging activities such as smoking and excessive alcohol drinking.

b) The second "difficult" group is liable to smoke and drink excessively. They may be taking illicit drugs. There are likely to be psycho-social problems. The compliance is poor. This latter represents a considerable problem because HIV becomes rapidly resistant unless the medication is taken in a prescribed way.

Three consultants are involved with the running of the HIV/AIDS service. One of these is a locum. There are also 2 clinical assistants (a total of 7 sessions). There are 4 SpRs all of whom are on rotational schemes. They are attached to the unit for 6 months at a time but sometimes no SpRs are available. There is one specialist full-time nurse.

Patients are initially seen every 2 weeks until the treatment has been well-established. Eventually an outpatient appointment every 4 months is appropriate.

The drug treatment costs about £10,000 per patient per year. At least 200 patients are on drugs. The drugs bill alone is between £1½ and £2 million annually.

There are other costs including particularly that of staff involved with treatment and monitoring and the running of the ward. The matter of cost is a considerable worry as the HIV and AIDS service is so expensive. The Department of Medicine at Southmead has been told that it must reduce its budget by about £2½ million per year. It is difficult to see where the savings in the HIV/AIDS service are going to be found.

Stuart Glover thinks that the HIV/AIDS service is likely to get busier during the coming years. This is particularly liable to occur if there continue to be so many people from Africa with HIV infections. Stuart Glover feels strongly that there is a need for more beds for this service and for the infectious disease service generally.