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HIV Services and QIPP


Executive Summary What is ‘QIPP'? HIV Services – the current picture Outcomes – Developing measures that matter Treatment – Developing clinical and cost effective prescribing in the context of choice Care – Developing approaches to meet the needs of people living with HIV Secondary Prevention – Reducing late diagnosis and promoting earlier testing Potential patient reported outcomes and experience measures for 2011/12 and beyond Possible CQUINs for 2011/12 and beyond London Clinical Outcomes Possible criteria for informing cost-effective prescribing choices BHIVA's ‘four faces of HIV' Executive Summary

This report is one in a series produced by the Specialised Healthcare Al iance looking at various
services, including HIV, which have been prioritised by the National Specialised Commissioning
Group in relation to QIPP (a policy which aims to deliver quality and productivity at a time of
spending constraint). This report was particularly informed by a stakeholder workshop on HIV
services organised by the Al iance and the London Specialised Commissioning Group on 10th
September 2010. A wide range of stakeholders including patients, commissioners, clinicians
and representatives from patient organisations attended the workshop.
The report sets out some background information on QIPP and HIV services before seeking to
distil the major themes explored during the workshop in relation to outcomes, treatment, care
and secondary prevention. For each theme, some context and background with regard to the
key issues is given (including some salient issues which it was not possible to discuss at the
workshop), as wel as an overview of the discussion at the event.
Among the most important points to emerge, attention is drawn to:

The importance of involving individual patients in discussion at an early stage about
potential efficiency savings, for example in relation to home delivery of drugs or the use
of generic medicines;

The need to look at clinical and patient outcomes in tandem and to use CQUIN as a
means of securing delivery;
The potential opportunity arising from GP commissioning to involve GPs more actively in
non-specialised care for people with HIV and to normalise important aspects of
prevention, notably testing;

The continuing need for improved IT to support al aspects of care.
What is ‘QIPP'?
Quality, Innovation, Productivity and Prevention (QIPP) is the flagship policy being used by the NHS to find the £15-20 bil ion of savings identified by Sir David Nicholson as necessary in 2011/14 as a result of rapidly rising demand for services and a chal enging fiscal climate.1 The overal aim of the scheme is to combine improvements in quality of care with efficiency savings which can be reinvested in front-line services. Ideal y, quality and productivity wil go hand-in-hand, providing a better service for the patient, as wel as cost savings for the NHS as a whole. The National Specialised Commissioning Group (NSCG) has prioritised ten services for taking forward the QIPP agenda, with each Specialised Commissioning Group (SCG) leading on one of the services. The London SCG is leading for HIV services. The Specialised Healthcare Al iance is looking at nine out of the ten services in relation to QIPP. The Al iance's aim is to ensure a balanced discussion between the four strands of QIPP and to                                                               1 For background on QIPP: The NHS Quality, Innovation, Productivity and Prevention Chal enge: an Introduction for Clinicians (March 2010), available here. identify any common themes which may be relevant to improving quality and efficiency in
specialised commissioning across the board.
HIV Services – the current picture

The Health Protection Agency (HPA) reports that in 2009, 65,319 HIV-infected individuals (of al
ages) were seen for HIV care in the UK, representing an increase of 7% on the number seen in
2008 (61,110) and a 250% increase on the number seen in 2001 (26,088).2 At the end of 2008,
the HPA estimates that there were 83,000 people infected with HIV, of whom over a quarter
(27%) were unaware of their infection.3 Today, HIV is classified as a complex, chronic medical
condition. At the same time, it retains several features which distinguish it from other long-term
Until 2009, ‘HIV al ages' was included in the Specialised Services National Definitions Set and so
was a commissioning responsibility of Specialised Commissioning Groups (SCGs). By that time
over 50 treatment centres were providing outpatient care, implying a planning population of
less than one mil ion and thereby fal ing below the statutory definition of specialised. As a result,
the third version of the National Definitions Set, which was published recently, no longer
includes al types of HIV care. Only complex HIV care and paediatric services are included
(these can be found in Definition 18 – Infectious Diseases4). While a number of SCGs continue
to commission al HIV care and treatment, in some cases commissioning for outpatient care is
being returned to Primary Care Trusts.
Under the government's proposals for England, set out in its White Paper Equity and Excel ence:
Liberating the NHS
,5 the new NHS Commissioning Board wil have responsibility for specialised
services through national and regional commissioning, as defined by the National Definitions
Set. PCT commissioning wil be undertaken by GP consortia. The future commissioning
arrangements for HIV are stil unclear.
Inpatient HIV care is currently covered by Payment by Results (PbR), while outpatient care is
not. Outpatient care is funded through local block or tariff arrangements. A project is
underway – sponsored by the Department of Health – which aims to develop a national HIV
adult outpatient PbR tariff for care. Progress to date has included the mapping of a standard
care pathway for three categories of HIV patient (new, stable and complex) and a ‘bottom
up' costing approach to identify the elements of the pathway, in order to derive national
average costs for each category.


The relatively high cost of treating HIV means that HIV services are likely to come under particular pressure to produce efficiency savings. In addition, the year-on-year growth of the HIV patient population makes these savings, which would be reinvested, essential. At the same time, there are opportunities to drive up the quality of HIV services, for example through the agreement and delivery of various outcomes to measure quality of care. 2 Link to web page: here 3 Link to document: here 4 Link to web page: here 5 Link to document: here Main Themes
Outcomes – Developing measures that matter

The government's recent health White Paper places great emphasis on the importance of
outcomes for the future of the NHS in England.
The purpose of this workshop session was to explore the outcomes which could be used to
measure the quality of HIV services. Two types of outcome were examined at the workshop –
patient-reported and clinical – as wel as CQUIN goals, which are a way of incentivising
outcomes. A focus on outcomes at the beginning of the workshop was designed to help set
the scene concerning the standard of quality which could and should be achieved in HIV
The main conclusions from this session were:

There is a need to fine-tune proposed patient-reported outcome measures in order to
ensure clarity and the recording of the most important and appropriate aspects of
patients' condition and care;

A key issue is the difficulty of data col ection in relation to CQUIN goals, which could be
solved through better IT systems;

The three sets of outcome should not sit in isolation; rather there should be clear links
between them.

PETs to PROMs? Measuring the difference for patients People living with HIV have a strong tradition of helping to shape the care they receive. This wil ingness on the part of patients to engage with their condition and care must be used to shape effective patient-reported outcomes for HIV. At present, Patient Experience Trackers (PETs) and other validated tools are used in the NHS to measure the experiences of patients including people living with HIV. While PETs are useful in measuring patient experience, they do not capture the totality of outcomes that matter to patients. Patient-Reported Outcome Measures (PROMs) are a careful y developed way of measuring the health gain to patients after a particular surgical procedure. The patient's health gain is typical y measured using short, pre- and post- operative surveys which are fil ed out by the patient and which measure patients' health status or health-related quality of life at a single point in time. While PROMs are currently being used only in relation to a smal number of elective procedures, the government's health White Paper sets out plans to expand the use of PROMs ‘across the NHS wherever practicable.' In addition, it must be noted that the approach used by PROMs questionnaires is not necessarily new. For example, mental health services and counsel ing services often use a framework to assess the impact of their intervention. Participants at the workshop were asked to look at and critique a set of potential patient-reported outcome and experience measures for 2011/12 and beyond (see Appendix 4.1). Some of the discussion concerned particular aspects of the potential measures. For example, the importance of patients not only knowing their latest CD4 count and viral load but also understanding the significance of these numbers was highlighted. In addition, the difficulty of capturing some of the measures was discussed, for instance that concerning the ability to improve adherence to treatment. It was also suggested that it is important to take into account and measure al aspects of a patient's condition and situation, including their social, housing and employment needs. More general y, it was agreed that any patient-related measures should not unrealistical y raise patients' expectations about the care they expect to receive. Similarly, measures should be based on what patients believe is important to them and must be presented in a way that is easy for al to understand. Final y, it was noted that it would be important to develop and agree patient-related measures (and clinical outcomes) relevant to children and young people, since adult measures are not always appropriate.
Commissioning for Quality and Innovation (CQUIN)

The Commissioning for Quality and Innovation (CQUIN) payment framework makes a
proportion of providers' income conditional on outcomes which demonstrate improvements in
quality and innovation in specified areas of care. The goals set by CQUINs may be described
as ‘stretch' goals since they aim to encourage improvements in the quality of care provided,
over and above core requirements.
Participants at the workshop were asked to comment on a possible CQUIN scheme for 2011/12
and beyond which sets out several goals and related indicators (see Appendix 4.2).
Stakeholders across al groups emphasised the difficulty of data col ection with regards to
CQUIN goals. At present, the col ection of data for many trusts involves case note review by
clinicians which is extremely time-consuming. It was felt that proper IT systems with appropriate
management would help to al eviate this issue.
Many stakeholders highlighted the importance of incentivising prevention to a greater extent
through CQUINs. At the same time, it was warned that CQUIN goals must not deter trusts from
treating more complicated patients.
London Clinical Outcomes
Stakeholders were provided with information on a set of clinical outcomes being used in
London. Unfortunately, because of time pressures, it was not possible to discuss these outcomes
in detail on the day. However, stakeholders were encouraged to record their comments on
the outcomes during the workshop or to email their comments after the event, including their
thoughts on whether it would be appropriate to rol out the London outcomes national y.
The London clinical outcomes have been produced with clinicians and the HPA and were
developed by combining surveil ance data from a number of surveil ance systems col ated at
the HPA.
The four clinical outcomes and the standards set by the London HIV Consortium can be found
in Appendix 4.3.

Treatment – Developing clinical and cost effective prescribing in the context of

Since the mid-late 1990s, people living with HIV in the UK have been treated using a
combination of antiretroviral drugs. This treatment approach is known as ‘highly active
antiretroviral therapy' or HAART and its aim is to reduce viral load to an undetectable level.
HAART is not a cure, but has brought about a vast improvement in terms of life expectancy and
quality of life for those living with HIV. It has also contributed to a reduction in onward
transmission as a result of reduced infectivity. At the same time, the use of HAART can induce
extreme side effects, some people can become resistant to certain treatment regimens and
the long-term consequences of life-long treatment are, on the whole, stil unknown.
HIV drugs are estimated to account for 65-70% of the total cost of treatment and care. At the
same time, the HIV patient population is growing each year as a result of the longer life
expectancy of people living with HIV since the introduction of HAART. A growing patient
population puts pressure on resources, as more people require treatment. Clinicians and
patients are already working together to come up with solutions to reduce costs such as home
delivery of drugs (drugs delivered to a person's home are not subject to VAT) and projects to
reduce drug wastage.
The purpose of the workshop session on treatment was to explore ways to ensure affordability of
effective treatments for the growing HIV patient population. Participants were asked to discuss
a list of possible ways to make the best use of limited resources (see Appendix 4.4). Various
issues needed to be taken into account, including current treatment guidelines and choice,
which are discussed below.
The main conclusions from this session were:

There is the potential to expand the use of home delivery of drugs, although caution is

Reducing drug wastage should be explored further as a method for saving money;
The importance of patient choice must not be overlooked when making prescribing

When considering cost-effectiveness, it is important not to consider treatment costs in
isolation, but to look at how the service is delivered as a whole.

Treatment Guidelines
BHIVA (British HIV Association) guidelines for treatment with HAART (2008)6 recommend that
treatment should begin in al patients with a CD4 count <350.
The guidelines also set out the Writing Group's recommendations for treatment options with
reference to both the stage in the patient pathway and any complications in the patient's
medical profile. For example, the guidelines recommend the non-nucleoside reverse
transcriptase inhibitor (NNRTI) efavirenz as part of the first line treatment of al patients based
upon the drug's ‘efficacy, durability, toxicity profile, convenience and cost.' However, in HIV
there is a high level of individualised prescribing in the context of the guidelines, based on
assessment by the clinician and patient in selecting the most effective treatment regimen. At
present BHIVA guidelines are not equivalent to NICE technology appraisals and draw on expert
opinion as wel as randomised clinical trials.
6 Link to document: here The BHIVA guidelines emphasise that HAART is extremely cost effective, but acknowledge that
the price of newly introduced HIV treatments is high, while generic drugs are becoming
Participants at the workshop felt that it was important for BHIVA to continue to set treatment
guidelines as a result of clinical evidence.
There was some discussion about the potential involvement of NICE, particularly with regards to
expensive salvage therapies. While some participants felt that the involvement of NICE would
be detrimental to patients, others suggested that those drugs which had been used as salvage
therapies are now being used for wider purposes and are perhaps not as expensive as once
It was acknowledged that the use of generic drugs could result in people taking more pil s per
day than usual. There was agreement that for some people with HIV, such as those who have
problems with adherence or who suffer from dementia, this would not be a viable option.
The volume of information available on treatment options and development (for example
NAM's monthly hiv treatment update) means that many people living with HIV have a very
good understanding of their condition and their treatment options.
The decision to change a person's treatment regimen may be a result of one or more of the
fol owing: a) toxicity/side effects, b) resistance, c) difficulties with adherence, d) patient choice.
It is clear that various factors influence the decision to prescribe a particular treatment regimen,
embodied by the differing viewpoints of the patient, the clinician and the commissioner, and
that al factors cannot carry equal weight in every instance. The issue of choice is made more
complex by the ever-growing number of treatment options, evolving attitudes concerning the
clinical efficacy of existing and new treatments, as wel as the emergence of previously
unknown side effects or long-term consequences for a person's health of particular drugs – al
of which must be considered in the context of limited resources.
The issue of choice was widely discussed at the workshop. Participants debated whether
clinicians should be able to make decisions on behalf of their patients, for example regarding
the number of pil s which a person should take each day.
Choice was also discussed in the context of home delivery of medication. It was recognised
that home delivery was not appropriate for al people with HIV. Examples of medication being
sent to the wrong address were given and the potential difficulties of home delivery to shared
housing were acknowledged.

Horizon Scanning
While it was not possible to discuss the issue of emerging HIV treatments in detail at the
workshop, it is vital to point out that the development of new treatments has moved at an
extremely rapid pace in the past and that this trend is set to continue.
In particular, as the number of older patients with prolonged exposure to established
treatments grows, the need to develop new drugs for those who show resistance wil increase.
A limited number of treatment options which fal into new categories of drugs, such as fusion
inhibitors, entry inhibitors and integrase inhibitors, have become available and others are in
Care – Developing approaches to meet the needs of people living with HIV

HIV services in the UK were first developed before the introduction of HAART and therefore
needed to provide a lot of scope for inpatient care. By contrast, most people living with HIV
today require very little inpatient care and are likely both to make greater use of outpatient
services and to have a greater involvement in their own care.
The focus of this workshop session was the group of patients that may be described as ‘stable'
(according to BHIVA's ‘four faces of HIV' – see Appendix 4.5) and the new models of care
required to meet these patients' needs. Participants were asked to consider a model of care
under development in North East London and elsewhere which involves the monitoring of
stable patients led by specialist nurses, a greater emphasis on self-management and the use of
technology and approaches such as e-clinics/t-clinics (blood test results are sent by email or
given over the phone). Participants also considered what role GPs should play in the care of
people with HIV. Key issues including the appropriate setting of care and patient support are
discussed in detail below.
The main conclusions from this session were:

Appropriate IT systems would improve patient care – a single national database would be
the ideal option;

Patient choice and patient need must be taken into account when making decisions
about a person's care;

GP involvement in the care of people with HIV stil creates debate, but is likely to become
essential as the patient population continues to grow.

Settings of Care

BHIVA Standards for HIV Clinical Care (March 2007)7 recommend that clinical care for
diagnosed HIV infection in adult patients should be delivered through ‘managed clinical
networks'. The design of these networks, which involve one specialised HIV centre with
associated outpatient units, reflects the reduced need for large numbers of inpatient beds and
an associated increase in the volume of care provided in an outpatient setting.
In early 2009, BHIVA consulted on a briefing paper on primary and community based care for
people living with HIV8 and a subsequent report on standards in primary and community care is
planned for 2010/11. While the BHIVA Standards (2007) recommend that people living with HIV
should be strongly advised to register with a GP, the briefing document highlights that GPs have
traditional y not played a major role in the care of people with HIV in the UK. It therefore sets
out the benefits of extending the role of primary and community care (for example, primary
care and community clinics can be more convenient than hospitals and primary care has
particular strengths in areas which have become important as people with HIV live longer, such
as cardiovascular disease prevention, blood pressure and lipid management), as wel as
various ways in which this could be done. If primary and community healthcare providers
become engaged to a greater extent in the primary care needs of people with HIV, greater
involvement in other aspects of care could be introduced. For example, GPs could take
responsibility for some aspects of monitoring of HIV infection for stable patients.
There was some acknowledgement at the workshop that there was a need to debate the skil s
mix required in caring for patients with HIV, as wel as the frequency of monitoring of stable
7 Link to document: here 8 Link to document: here patients, to ensure that consultant expertise is focused on the most complex patients. At the same time, it was recognised that it would be important for the lead clinician to retain clear accountability for their patients. There was broad agreement that patients who are seen most regularly by a specialist nurse should have an annual comprehensive assessment by their clinician, which would include a social and psychological review. It was felt that this would help to improve the quality of patient care, while ensuring that the consultant's time was used most effectively. Some stakeholders believed that it was important for people with HIV, particularly those who are newly diagnosed, to be encouraged to see their GPs for various aspects of their care which are not directly related to the monitoring of their HIV infection, with some suggesting that GPs could eventual y take on a more direct role in the monitoring of the infection. On the other hand, some participants felt that patients would receive better care if they were treated, even for routine health issues, in an HIV clinic. These people argued that specialised clinics know their patients and their needs and that referral for any complications can be done quickly and easily from this setting. In addition, it was argued that there is no clear evidence that providing care in the community is cheaper than in a hospital setting and that training up GPs to give appropriate care and support to people with HIV would itself cost money.
More general y, it was widely acknowledged that even within the ‘stable' cohort, there would
be variation in need. Patients should be aware that they are seen to be within this cohort and
there should be clear mechanisms in place for deciding when a patient should be moved in or
out of this group. In addition, it was recognised that patients should retain some choice over
the care which they receive, including the setting of this care. Final y, it was noted that it is
important to understand that an increased role for community and primary care works in some
settings, but not others. In Brighton, for example, this model has proved successful principal y
because the gay community in the city has good links with GPs.
There was also general recognition that better IT systems would improve patient care,
especial y if care were to be provided in different settings by a number of healthcare
professionals, as wel as help to reduce duplication.

Patient Support
The AIDS Support Grant is paid to local councils to meet the additional costs of social care
support for people living with HIV. However, in July 2010, the ring-fence protecting the Grant
was removed, meaning that there is no obligation for councils to spend the Grant on HIV social
care services. It has been argued that without provision of social care support in the
community, there wil be a greater pressure on healthcare professionals in clinical settings to
provide this support.
The role of the voluntary and community sector is key in providing support to patients. There
are many organisations providing different kinds of support across the country. The Positive Self-
Management Programme, for example, is run by the Living Wel scheme, while Terrence Higgins
Trust provides a wide range of support services, which include emotional support, practical
advice on employment, immigration, housing and finances and contact with support groups.
There was general recognition at the workshop of the importance of providing support to the
ful set of needs of people with HIV. The benefits of providing proper support to people with HIV
are clear and include the likelihood of individuals showing greater adherence to treatment
regimens as wel as maintaining regular clinic attendance.
Transition and End of Life Care

Unfortunately, there was not time at the workshop to cover the issues of transition from
children's to adults' services for people with HIV and care for older people with HIV. However,
a brief overview of the current situation with regards to these key issues is given below.

Definition 18 of the National Definitions Set explains that the decline in mortality rates among
children has led to new chal enges for multidisciplinary teams as children grow up. The
document explains that many centres are now developing combined adolescent clinics with
adult HIV teams.

End of Life Care
The effects of long-term treatment of HIV are stil unknown. As stable patients grow older, their
condition is likely to become more complex. A greater number of problems is now recognised
as being associated with the virus and/or its treatment, for example an increased risk of
cardiovascular disease, liver disease, various cancers, kidney disease, osteoporosis and
neurocognitive disorders. It is clear, however, that whilst end of life care for people with HIV has
changed significantly with the reduction in mortality, future needs are likely to be complicated
and, to some extent, the care requirements for such people are stil unknown.
One of the benefits of an increased role of primary and community care in HIV services as set
out in BHIVA's briefing paper is concerned with care of older people. The paper stresses that,
unlike primary care providers, HIV specialists wil be il -equipped to cope as increasing numbers
of people with HIV reach old age and develop a range of co-morbid conditions and social
care needs.

Secondary Prevention – Reducing late diagnosis and promoting earlier testing

Primary prevention of HIV involves actions aimed at stopping people from becoming infected
with the virus. Preventing the 3,550 HIV infections that were probably acquired in the UK and
subsequently diagnosed in 2008, would have reduced future HIV-related costs by more than
£1.1 bil ion (HPA).

Secondary prevention of HIV is vital since the early identification of HIV infection means that a
person is more likely to respond wel to treatment and to remain in a ‘stable' condition (see
above). Decreasing late diagnosis of HIV is therefore the central aim of secondary prevention
of HIV (early diagnosis is also closely linked with primary prevention, since individuals with HIV
who are aware of their status are less likely to engage in behaviour which could result in the
onward transmission of the infection).
Late diagnosis is the most important factor associated with HIV-related morbidity and mortality
in the UK and has been associated with impaired response to HAART, as wel as increased cost
to healthcare services. According to the HPA,9 in 2008 an estimated 32% of adults aged over
15 years had a CD4 cel count <200 within three months of diagnosis (a CD4 count <200
remains the definition for late diagnosis, although the recommended threshold to treat has
been changed to <350 – in 2008, over half of patients were diagnosed with a CD4 cel count
<350 within three months of diagnosis). In addition, national surveil ance data show that over a
quarter of al HIV infections in adults in the UK remain undiagnosed.
This session focused on the importance of secondary prevention and the potential methods for
reducing late diagnosis. Various issues were taken into account, including the potential setting
of testing and the normalising of testing. These are discussed in more detail below.
The main conclusions from this session were:

Testing must take place in those settings recommended by the UK National Guidelines;
Testing should take place in further settings, such as in A&E departments in areas of high

We should learn from the successes in introducing universal testing in antenatal settings;
Testing should become normalised. A shift in attitudes towards HIV testing is required;
When GPs take over responsibility for commissioning outpatient HIV services, this could
facilitate a greater role for primary care in testing and early diagnosis.

Testing Testing guidelines and settings The UK National Guidelines for HIV Testing 200810 recommend that an opt-out approach to HIV testing should be implemented in GUM clinics, antenatal services, termination of pregnancy services, drug dependency programmes and healthcare services for those diagnosed with TB, hepatitis B, hepatitis C and lymphoma. Testing services are also increasingly being offered by voluntary sector organisations outside of clinical settings. The Department of Health has funded eight projects across the country which are piloting HIV testing in healthcare and community settings. A pilot in Brighton, for example, involves al new registrants aged 16-59 at 19 GP practices being routinely offered an HIV test. Stakeholders at the workshop felt strongly that testing must take place in those settings 9 Link to document: here 10 Link to document: here recommended by the Guidelines, particularly in TB clinics, where it was reported that testing is not happening as widely as it should. It was also recognised that although BHIVA testing guidelines recommend that in areas where the prevalence of HIV is more than 2 in 1000 any person who registers with a GP should be offered an HIV test, testing take-up rates suggest that at present this is not happening. Stakeholders recognised that it is possible that GPs perceive HIV testing to be more time-consuming and complicated than it is in reality. However, there was wide agreement that pre-test counsel ing is no longer required and that in fact in most cases this is no longer the normal practice. There was also broad agreement concerning the widening of settings of HIV testing. This could involve targeted testing to include, for example, gay saunas, as wel as universal testing in A&E in areas of high prevalence. It was suggested that a CQUIN goal could be introduced on testing in A&E and the importance of setting outcomes on prevention more general y was highlighted. ‘Normalising' HIV testing One of the main aims of the 2008 testing guidelines is to reduce the stigma around HIV testing by ‘normalising' the process, particularly within clinical settings. Terrence Higgins Trust is campaigning for the introduction of a national screening programme which it argues would reduce the stigma of having an HIV test. The programme would distinguish between areas of high and low prevalence and would be targeted at particular populations which are at greater risk, but would also maximise opportunities to test within the NHS and would encourage the rol ing out of community testing. There was strong agreement at the workshop that a significant shift in attitudes towards HIV testing is required. It was felt that this was the responsibility not only of the voluntary sector, which has traditional y taken on this role, but also of healthcare professionals, particularly those working in primary care. The issue of a national screening programme was raised, with some stakeholders suggesting it would be unfeasible, but with others highlighting that the possibility of such a programme would at least spark important debate. Appendices
Potential patient reported outcomes and experience measures for 2011/12 and

Type of goal
Description of goal
Possible measures
Patient Experience To ensure services are Services undertake an annual survey of experience and publish the results satisfaction and delivered with the Services have a patient forum or equivalent Services col ect and respond to comments, compliments and complaints Patient Experience To improve patient Patients involved in decisions about their care and supported to self manage as satisfaction and support patients to measured by responses to three questions in self manage their HIV a survey: • Were you involved in decisions about your care and treatment? • Were you given ready access to information about your condition? • Were you supported to manage your Patient Experience To ensure patients are Patients know their latest CD4 count involved in their care satisfaction and Patients know their latest viral load Patient reported To measure impact of Ability to participate in usual activities (work, outcomes (measure of HIV care and housework, family, leisure) treatment on overal health and wel being Experience of pain Experience of side effects Experience of anxiety/depression Ability to improve adherence to treatment Ability to make improved lifestyle choices eg giving up smoking, doing exercise etc. Possible CQUINs for 2011/12 and beyond

Please note that the patient experience goal on self-management, normal y included as a
CQUIN goal is omitted below since it was discussed as part of patient reported
outcomes/experience measures (see Appendix 4.1).
Type of goal
Description of goal
Description of indicator
To ensure HIV therapy Patients with no resistance on NNRTI (non-nucleoside reverse transcriptase inhibitors) therapy Patients failing therapy re-suppressed within 6 Patients with a CD4 <200 on therapy Adherence to ART documented To support primary and HIV patients with positive STI results have health secondary prevention advice and support Patients notified for TB (or other indicator conditions) Enhance partner notification of newly diagnosed to Patients with 10-year cardiovascular disease risk Annual assessment of weight, blood pressure, BMI To increase the role of Annual correspondence with GP where patients primary care in the have disclosed their HIV status care of HIV patients London Clinical Outcomes
Patients included
in the analyses

Outcome 1: Time interval
To ensure patients between HIV diagnosis and diagnosed patients date of first CD4 count at the with HIV are receive a CD4 cel same centre. This is used as a promptly integrated count within 28 proxy for date of the first appointment with a clinician. Outcome 2: Viral load <50
85% of patients who Patients with a VL and stil on therapy 1 year effectiveness of started treatment after therapy first started. have a viral load after 9-15 months Outcome 3: Patients to have To monitor immune
90% of patients in Patients in clinical CD4 ≥ 200 after 1 year or status of patients care should have a after one year or centre for a year more of HIV clinical Outcome 4: Proportion of
To identify early No standard, death Patients newly patients stil alive by 1, 2, 3 rate calculated. years from HIV diagnosis, patients recently stratified by CD4 count at receiving HIV care. Possible criteria for informing cost-effective prescribing choices
• Switch patients to cheaper alternatives, including moving from one to more pil s a day; • Use of generic drugs; • Home delivery as the norm; • Programmes to reduce drug wastage; • Standardised treatment guidelines to manage use of new/expensive drugs; • Prior approval/peer review for use of the most expensive drugs; • Threshold for treatment (eg not at CD4 > 350 unless AIDS diagnosis/Hep B/C co-infection or enrol ed on clinical trial); • Divert funding from ‘care' to ‘treatment'. BHIVA's ‘four faces of HIV.'

This model sets out four different patient profiles, including an outline of the care that each
should receive:
Stable – HIV treatment and care is relatively straightforward, no major social or medical
issues complicating HIV care. Scope for increased self-management, as long as there are clear links and support from clinical services; • ‘Co-morbid' – care is medical y complex as a consequence of co-infection, ageing,
effects of long-term treatment such as for osteoporosis, cardio-vascular disease, HIV or non-HIV malignancies and neurological conditions. Requires specialised care but needs are mostly predictable; • Complex social problems – individuals with issues such as housing, drug or alcohol use,
significant mental health issues or neuro-cognitive impairment. Characterised by erratic attendance, poor adherence, failure to achieve and maintain virological suppression. Needs cannot be met in a traditional, clinical setting as it is often difficult to retain them within services. • ‘Wild card' – previously undiagnosed infection, presents as an emergency at a centre
without HIV specialism with, for example, Pneumocystis Pneumonia (PCP), and is difficult to plan for.


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Journal of Drug Issues 31(2), 325-394, 2001 Nicotine as an Addictive Substance: A Critical Examination of the Basic Concepts and EmpiricalEvidence Dale M. Atrens Dale Atrens received a B.A. from the University of Windsor, an A.M. from Hollins College, and a Ph.D. from Rutgers University. He has heldappointments at universities in North America, Europe, Asia, and Australia. He is currently a Reader in psychobiology at the University of Sydney.He is the author of several neuroscience textbooks and a number of popular books on diet and lifestyle.

Depth dependent properties of ito thin films grown by pulsed dc sputtering

ARTICLE IN PRESS Contents lists available at Materials Science and Engineering B Depth dependent properties of ITO thin films grown by pulsed DC sputtering A. Sytchkova , D. Zola , L.R. Bailey , B. Mackenzie , G. Proudfoot , M. Tian , A. Ulyashin a ENEA Optical Coatings Laboratory, via Anguillarese 301, 00123 Rome, Italy b Oxford Instruments Plasma Technology, Yatton, Bristol, BS49 4AP, UK