15:28

pozniak

Is crazy because in the second generation into grazes you can see this. The barriers resistance is very
high. Everybody gets viral suppression really rapidly compared with say in an RTIs or the proteins
inhibitors. And we also see there's much less drug interactions and we've got data now at a five years
about how durable they are. And here's the study of an involved with you can see here in 1489 and
4090 that in the in the the red line they're filled in red dots. Those people are on therapy all the time,
and take their therapy up after follow-up of don't transfer out, etc, etc. You can see here, 90 over 9

The five years, The other graph really reflects our lives as physicians. When patients move, they get
transferred and other things happen to them. And some of them stop therapy. But the major thing
you can see from this that we've not seen on this triple therapy of theft. Any emergent resistance
detected out to five years

So treatment burden and regular clinical monitoring really important subjects. Look at this. Now we
have 10

And one injectable antivirus of all of the momentum has been licenced. And now we're going to have
you're going to hear more about another.

With is what the patients.

15:33

In therapies, we started to be met at we started, the medicalized treatment, For example, in my

clinic, you have your six-month prescription, you go away for six months. You may see a nurse from
one of your visits have all your bloods done have a review. See the physician once a year, it's very not
medicalized at all. Whereas when you have injections, you're coming back, like a monthly or two
monthly, you're starting to remedialize the whole system. So, we have to be careful when we have
this thing about long acting about remedializing the whole issue of HIV. So we have to simplify, we
have to make sure patients can do things into the community. Have they have their treatments
outside of any settings?

So what about the impact of clinical monitoring? Well, we should be very flexible and also we should
make sure that the drugs we give are minimal drug interactions. That have to do emergency visits to
come back in and we really need to make sure that as patients get older and then they're more
cohorted conditions, the therapies would give them don't interfere with anything they're pract. In
the community might give, I don't know about you but many of my patients that go to their general
practitioner they get more for another specialist, they get given and therapy, they come back to the
clinic and I'm going, oh no, you're taking 20 times the dose. Did you know that or half of the dose?
Did you know that? Because of the interaction with the HIV drugs, So it's very interesting about this
that if you reduce clinic and visits and you're going to see these slides again and I'll be going into
more detail if you reduce

And you can see here that the people a more likely to stay in care, is they actually reduce their time
to come? Also, you know, people are families. Oh, they have favourites then jobs. They don't want to
have to take days off work, or days away from their children, and family to have to come to clinic. So,
although this is very obvious to us all when we're looking at the next and we're working day today, it
may not trigger something. We need to start thinking about it. Every day about how is the way my
clinics run impacting on my patient's lives? Can I make it easier?

So obviously, we've now got, especially with the second generation integrated, it's very good drugs
and even with these nice second generation NRTI with very good drug interaction profile and so, if
you don't have drug interactions, you don't have to worry about other people, prescribing various
things or over the counter products and also you, you're much more likely to have patients who
remain well on their therapy with few side effects as therefore they are the deer to them.

We haven't got an ageing population and really put all I want to show you in this is if you look at
these various age groups you can see in the green these are people with with three or more
commonities as they say as they age and we're going to see and I'm sure you've got lots of patients
with multiple kernelities and it's always the sort of, oh no, I've got to write a letter for a

15:37

That by the time we get to 2013 at least half of all our patients and some units that's already
happened. Are going to be over 50 or over 60 years old. So, this is something we have to watch out
for. When we prescribe our therapies, we have to be very careful about what we're giving to patients
that don't interact. I want to really now emphasise about the quality of life. It's universally important
for. Yeah, that's what it's universal for. All of us, it's important and we really got to think about how
we measure that there are these things called patient, reported outcomes. And really if you haven't
heard much about it, you will do during this. This did this session.

15:37

And I think that it's really important to be focused on what do the patients, think their outcomes are
being given therapy are what are the health care professionals their nurses. The pharmacists, the
doctors who give you, what do they mean? The outcomes are so that when we look at those, we can
actually develop our services to help give better plans to the future.
I talked about the drug interactions at the other, the other message that I'm sure you're giving to all
your patients. Is this u equals you undetectable, right means I'm transmittable but actually the
message hasn't got quite out there for everybody yet mental health. Well as you know that's a really
major issue being diagnosed nationally. Positive can make people feel very down and depressed. I
can make them feel very anxious and that anxiety depression can last quite a long time and so
mental health issues, some people get HIV because of their mental health. The terminal. But into
that they have is something we have to be interested in. Now, I've been part of a group who've
talked about this fourth 90, You can see all these targets, okay? That targets most of them will
achieve their heads in 2020, but many countries did 95 95, 95s only two years away, right? So that's
very, you know, it's a big target but there's a proposed soul which is very good quality of life, The
health related quality of life,

15:39

This studies I've been involved in. You can see here that actually in the red which favours BF tab in
terms of all

The patient might have about nausea sleeping appetite and etc etc. And you can see at the bottom
nervous and the things that I see impressed and so are interesting things. That.

Not actually switch therapy in the second generation. Integrated switching them away from their
other therapies. If we've almost landed off of anyone left on a beverage,

To the second generation integrated to that. And even though the patient says, I've got no
symptoms. We switch them. Ask them to come back and they say, hey, girls sleeping better. I don't
have such crazy dreams anymore, feeling more energetic. So it is interesting. Although they may not
complain of issues that they may well have them and that's where these patient related outcomes
come in patients. May all may not talk about symptoms. We also made the involved in trying to
predict what these outcomes should be. Yes, you should be sleeping best but sleeping. Well, I had on
a minute then just checking now, right? And the patients also I can play are there is symptoms, they
change their drugs and suddenly things are better. And the impacts of the disease on their daily life is
better. They're not saying everyone should switch drugs, but there are certain things we can do to be
able to be aware of when we're treating patients to understand that, actually we can The quality of
their life. And one of these things about patient related art comes from standardising them and
measuring them.

Now by doing these, you can increase knowledge, especially that they're might be depressed. You
can improve many things that go on about documentation of what they are complaining about and
you could really enable people to be empowered and to to really identify their concerns and
overcome those. Whereas if you just say, oh you're fine, you're only technical, you see me falls 800,
you've got notes on your field, goodbye and doesn't address anything in this, Okay? So that we need
to start addressing people's quality of lives.

You can see here about the undetectable equals and transmittable and it's really very interesting that
health care and professionals it ranges from 38 to 87% about who talks to them. And I noticed here,
there's a lot of career people living here there. But I saw this on a wising career and I'm discussing
you through. You was in Switzerland who invented you, it was usually invented by the whole concept,
most of the healthcare professionals talk about it. So I will put a challenge to you is that next time
you feelings think about having times? You're gonna mention this to patients? And when I try to find
something yeah, sometimes forget about that.

Mental health, even to get more about this as well. And obviously there are a lot of factors about and
will help and we can't underestimate how mental health affects quality of life. Mental health, affects
endurance, mental health, affects attendances. It affects the way that people react in clinics. We
want about biggest issues in my company, a patients, who mental health problems. We have a whole
group in the clinic who are more specialised in dealing with patients, who mental health to the car
after these, and they're very vulnerable population. So this all comes into integrating healthcare as
lighter in a life, long way. And I'm going to talk about this tomorrow. So I'll definitely go quite quickly
with through this. I'm going to really talk about the fact that the linearity that we've come from and
we still have it in our units, a bit from being the boss people underneath the patients, Finally is a
relative, it's bigger linearity. We changed it now to a multi-disciplinary team, So you can see here in
this. It's all around the patient now and I understand that people may have a model of care and in
Chinese just part of it and but a multidisciplinary team can work in all aspects of infectious disease
with HIV. Really use this way of developing your multi-disciplinary team, first of all, using HIV. Is your
model and you can see here by having integrated MVPs, you're much more, likely a patients
becoming undetectable and much more likely of people as being endurance, using pharmacists using
the nurses to more case manage. And as I said tomorrow, I will talk about case management. The
other thing, it does by having multiple teams and improves the understanding of patients, what they
know about their HIV and it's quite incredible that patients come in and I say, what pills you are, I
didn't really want, what do you know about ABC? Oh, I know that I just got to take my pills every day,
right? So the electricity of patients who can improve and then the pharmacists they're being rolled
and nurses. They've been role appear supporters, play a big role and if you

Patients. They're more likely to be a deer and they understand the reasons more deeply about why
they should be taking their therapy and they understand their reasons, why they should turn up to
their appointments more. So this is really important.

Information technology, just because you've got the app doesn't need, you can use it for the right. So
just because you have all the information technology we should be using it more in a smarter way.
And we use this a lot. Now, in communication with our patients, our patients can get their results,
they can question us about their results and we contact our patients and coding studies. A lot in
terms of the way that we can communicate with patients. Now we can we can do a lot and a patients
are uncertain about various things. They can actually use communication methods to actually resolve
those uncertainties and not wait, six months till they come back.

And finally stigma and I just I'm going to click and go through this because freedom from stigma
discrimination is going to be one of our big goals and one of the problems is you can see here are in
the graph. Only 30% of countries do not. You can see it. Do not require parental, consent for HIV
testing, imagine the fury on first one. In HID test. You have to go and ask your parents. I mean,
remember when you're all 16, 17 years old and actually go to your parents and say, excuse me, could
you take me to an HIV test? I mean, it's just something that we have to overcome. So there's a lot of
policies that are a lot of things that we have to do fight for on behalf of our patients to try and
improve things.

You can see here, don't have to read the details, the slides will be available. That's in the yellow.
Many, many cases. You can see there are people who had this crimination against them, right? A lot
of people have done this and there is also discrimination from health care professionals, it's
absolutely true in your own excellent. You have to keep your eyes and even sometimes we say things
to each other and you then think that on a bit of that, maybe a little discriminator right because oh,
that person that keeps coming up, they're all this community shouts and they're always demanding
instead of saying why they like that, we have a way of talking about. So we have to start thinking
about Stickware, discrimination and different way.

Pasties have a, some of them have a severe in-built problem, because they see societies judging
them because they're actually positive and they have this, they start to grow a self-stigma inside. And
again, we can with our colleagues, the most disabilities try and give them health. We have a whole
system of peer support people who are actually who come to academic and volunteer, they talk to
such people about what it feels like. And obviously it's more severe. They can see psychologists and
the mental health team. So in conclusion, it's not just about viral load, it's not just about immunity.
It's not just about coming to take your pills and take them all. There are a lot of things that we have
to be mindful of. I'm not seventy over the ball but we have to keep mindful of Patients from long
terms in the success and this is the framework that I showed patients all should be able to have and
live for the best personal possible life. And this is a really good model to try and help us and let the
patients help help help us they'll help us will help them in terms of achieving this and with that I'd
like to thank you very much.