Section 10 -

Expert Referral Centres For HIV & Emerging Infection Pathology: The United Kingdom Sebastian Lucas

Demographic summary The population of the UK is 60 million with a growing proportion of recent immigrants and many travellers overseas. The total number of people with HIV is estimated at about 60,000, with one third of them not knowing they have HIV infection. The single largest cause of death in those with HIV is late presentation with HIV-related complications, the diagnosis of HIV being made only in the last illness which is too severe to cure. Earlier diagnosis of HIV, including pre-symptomatic, would make the largest contribution to improving the outcome and survival of those with HIV. Classical tropical infections are common in the UK, with (eg) more than 2000 cases of falciparum malaria imported per annum. [see Health Protection Agency website] Whilst HIV and other infectious diseases are seen in all regions of the UK, there is significant asymmetry in geographical distribution. Historically 65% of all HIV and imported tropical disease cases are encountered in London and the south-east, whilst having only 20% of the total population. Unsurprisingly, this is the area where pathological expertise is concentrated. Disposition of cellular pathology in the UK Cellular pathology in the UK is predominantly organised through the National Health Service and universities, with a small but growing contribution from private laboratories. There are about 1300 senior pathologists employed by about 240 hospitals and 20 medical schools. Specialisation Increasingly, cellular pathology is becoming specialised with pathologists focussing on a small range of diseases, all organ-based (eg gut, lung, skin, gynae, nervous system); the only exception is forensic pathology. This specialisation is driven by the cancer networks and the development of tertiary cancer centres for regions. Infectious diseases is not a recognised subspeciality of histopathology, although infections occur across all organ systems. The competence of histopathologists in evaluating infectious diseases varies greatly and it is not considered as important as the correct diagnosis of cancer. Centres that specialise in HIV or tropical/infectious diseases do not have designated pathology posts that focus on these diseases, with appropriate funded time sessions. Limited exception to this pattern are the pathologists who specialise in liver disease, who are familiar with the hepatitis viruses; haemato-pathologists who know about EBV and HHV8 infection; and neuropathologists who evaluate viral encephalitis and toxoplasmic encephalitis. Tropical and infectious disease experience The number of pathologists who have worked in resource-poor countries as part of their training is less than it was 30 years ago, in part as training programmes have become more organised, output-driven, and less flexible. As the older experienced pathologists retire, the pool of those with significant ID experience is shrinking. Autopsy experience in HIV disease is highly selective, as the infection is distributed predominantly in the south east of the UK. The total number of HIV+ deaths is currently about 500pa. Few pathologists have any significant experience. About half of deaths of HIV+ persons in UK are caused by immunodeficiency; the other half are from other unrelated diseases, suicide, accident, drug overdose. Because of fear of infection on the part of pathologists and mortuary technologists, the majority of mortuaries in the UK do not accept cases with known or suspect hazard group 3 infections (including HIV, TB, HCV). This leads to concentration of the activity in a smaller number of centres. There are protocols for HIV (and other infectious disease) autopsy work on the Royal College of Pathologists website [see Publications section]. A number of departments performed routine diagnostic histopathology for hospitals overseas (eg in Africa) by post. This has provided material for experience and training. This activity has declined for several reasons: overseas hospitals closed because of civil disturbance; some hospitals re-used the central laboratory; UK hospitals raised the costs of such charity work until it became unsustainable; the original UK pathologists who sustained it retired. Infectious disease pathology expertise in the UK that covers the broad area of HIV disease, tropical diseases, and possible emerging infections is thus limited. It is focussed on a very few individuals who have taken an interest and become reference experts by reputation, on the back of their formal job which usually does not include this expert activity. A typical single-handed London-based specialist will do more than half of all the HIV autopsies that are performed in the UK, chair the annual clinico-pathological reviews of all HIV-related pathology in the local regional HIV centres, and receive a large number of postal referrals of ?HIV-related disease. Referrals and charging Traditionally, referring cases of expert advice on any aspect of cellular pathology, via blocks and slides, has cost nothing to the sender apart from postage. Increasingly, hospital departments are insisting that their consultant pathologists invoice the sender for the consultation. The usual fee is about £250 ($475) depending on amount of immunostaining or molecular diagnostics required. To maintain ID referral practice and expertises, it is important that such charges should be resisted. Also it inhibits pathologists from sending problems to be evaluated. BHIVA support In UK, the main advisory body on HIV is the British HIV Association (BHIVA). It functions to hold conferences and produce guidelines and standards of care for those with HIV infection in the UK. Clinically, HIV medicine is not yet recognised as a specialty differentiated from Genito-Urinary medicine; it is combined within GU medicine in the Royal College of Physicians; it has a Diploma with the Society of Apothecaries, but this diploma is not (yet) regarded as an essential to a senior clinical appointment with an interest in HIV medicine. Thus, not surprisingly, there is no HIV subspecialty within the Royal College of Pathologists either. BHIVA guidelines do incorporate some pathology material (eg the Tuberculosis co-infection guidelines [see website]) where the importance of autopsy analysis following death in those co-infected is emphasised. Succession planning Because of more limited ID experience among the younger pathologists, they are going to have a sharper learning curve than their seniors, when faced with diagnostic problems. There are few international centres to which aspirant specialists could go for more experience: the USA AFIP is one, and the French Institute Pasteur units constitute another. In the end, most such specialist learn from personal experience and from diagnostic mistakes. Links with overseas HIV and ID research centres is another means of acquiring experience. However, in comparison with clinical medicine and microbiology, cellular pathology is not currently so much in demand that resources at the home and overseas ends are available for such links. Perhaps this will change as the importance of HIV and ID cellular pathology and diagnostics is appreciated in the growing HIV pandemic. Prospects for ID pathology in the UK There is a planned modernisation of UK pathology, now being piloted in England & Wales. This involves more centralisation of the high volume blood-based laboratory medicine sectors (haematology, chemical pathology, microbiology). The impact on cellular pathology is not certain, but presumably will continue the current slow amalgamation of smaller units and development of networks primarily based on cancer diagnostics and management. There is no reference to infectious disease pathology in any recent government plans concerning clinical or laboratory medicine, and it is unlikely that cellular pathology will embrace ID as a sub-specialty. This means that it will continue as before, with a small number of self-selected individuals taking an interest. They will acquire experience through direct and referral practice. It is unlikely that there will be central funding for cellular pathology ID expertise, on the grounds that this has never happened before. References UK HIV demographic data (March 2006) http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemiology/files/2006_Q1_Mar_HIV_Quarterlies.pdf BHIVA website: www.bhiva.org Royal College of Pathologists website: www.rcpath.org