Case 8

1
Case 8

• 38 year-old man from Sub-Saharan Africa
• Came to UK in 2001
• Living in London
• First wife died 10 years ago of TB
• Remarried for 7 years, wife currently pregnant
  (antenatal HIV screening negative)

2
Case 8 PMH

• 2001 Registered with GP
• 2004 Hypertensive treatment started
• Recurrent knee problems
• 2006 Arthroscopy - conservative treatment
  recommended
• 2007 PUO/suspected malaria
• Admitted for 48 hours and found to be anaemic
  (Hb 9.8)
• Treated with anti-malarials and antibiotics.
• HIV test not offered
• 2008 gt10 kg weight loss noted
• Said he had been trying to lose weight as
  previously overweight

3
Case 8 late July 2009

• Presented to GP with
• Flu-like illness
• (presumed H1N1 treated with Tamiflu)
• Herpes Zoster left trunk
• Offered HIV test
• HIV positive
• CD4 189
• Viral load 90,000
• Hb 8.7

4
Case 8 summary

• 2001 Registered with GP
• From 2004 Seeing GP for hypertension
• 2006 Pre-op screening - arthroscopy
• 2007 Admitted for PUO/suspected malaria and
  anaemia
• 2008 GP notes gt10 kg weight loss since Nov
  2007
• 2009 Seen by GP for Herpes zoster
• HIV diagnosed CD4 189, VL 90,000

5
Q At which of his healthcare interactions could
HIV testing have been performed?

• When he first registered with his GP?
• When he saw GP for hypertension?
• When he was admitted by the orthopaedic team for
  arthroscopy?
• When he was admitted for PUO/malaria and noted to
  have anaemia?
• When his GP noted his gt10kg weight loss?
• Should he have been referred to GUM to see a
  trained counsellor before HIV testing?

6
Who can test?
7
Who to test?
8
Who to test?
9
Who to test?
10
Who to test?
11
Who to test?
12
Rates of HIV-infected persons accessing HIV care
by area of residence, 2007
Source Health Protection Agency, www.hpa.org.uk
13
At least 5 missed opportunities! If current
guidelines used, HIV diagnosed 8 years earlier

• 2001 Registered with GP
• From 2004 Seeing GP for hypertension
• 2006 Pre-op screening - arthroscopy
• 2007 Admitted for PUO/suspected malaria and
  anaemia
• 2008 GP notes gt10 kg weight loss since Nov
  2007
• 2009 Seen by GP for Herpes zoster
• HIV diagnosed CD4 189, VL 90,000

14
Learning Points

• This patient came from an area of high HIV
  prevalence, but was not offered an HIV test in
  numerous contacts with healthcare services
• His wife had tested HIV-negative, but this is no
  guarantee of his being HIV-negative
• A perceived lack of risk should not deter you
  from offering a test when clinically indicated
• HIV screening should be a routine test on
  presentation of a blood dyscrasia, PUO or weight
  loss of otherwise unknown cause

15
Key messages

• Antiretroviral therapy (ART) has transformed
  treatment of HIV infection
• The benefits of early diagnosis of HIV are well
  recognised - not offering HIV testing represents
  a missed opportunity
• UK guidelines recommend universal HIV testing for
  patients from groups at higher risk of HIV
  infection
• UK guidelines recommend screening for HIV in
  adult populations where undiagnosed prevalence
  gt1/1000 as it has been shown to be cost-effective

16
Also contains UK National Guidelines for HIV
Testing 2008 from BASHH/BHIVA/BIS
Available from enquiries_at_medfash.bma.org.uk or
020 7383 6345