Enhancing HIV Testing in Medical Settings: A Call for Action

1. The case for increasing HIV testing in all medical settings

2. All-cause mortality pre-1996 and 2004-06 (sexual exposure only) 1.0 <45 years at seroconversion >45 years at seroconversion 0.8 0.6 0.4 0.2 0.0 0 5 10 15 0 5 10 15 Fig 1 Fig 2 Estimated cumulative mortality Time since seroconversion (years) Pre-1996 (HIV infected) 2004- 2006 (HIV infected) 2004- 2006 (general uninfected) Porter K, et al. 15th CROI 2008 Abstract 14

3. Estimated prevalence of HIV infection in adults*in the UK at the end of 2007 • Aged 15-59 inclusive - excludes those who have died during the year Fig 3

4. Estimated late diagnosis 1 of HIV infection by prevention group, UK: 2007 Fig 4

5. Estimated prompt1 and late2 HIV diagnosis3 in MSM with associated short-term mortality4: UK (1998- 2007) Fig 5 Fig 6

6. Estimated prompt1 and late2 HIV diagnosis3 in black Africans and Caribbeans with associated short-term mortality4:UK (1998-2007) Fig 7 Fig 8

7. Cost of care after HIV diagnosis in Canada 25000 20000 15000 CD4 <200 CD4 >200 10000 5000 0 <1 year >1 year <1 year >1 year <1 year >1 year <1 year >1 year Total Inpatient Outpatient ARV drugs Cost category Fig 9 Mean cost (C$) Gill WJ, Krentz HB. Poster 12C1070. 11th European AIDS Meeting, Madrid, 24–27 October 2007

8. BHIVA Audit 2006: Scenario leading to death Top bars: reclassified during audit Bottom bars: as initially reported Fig 10 Source: Mortality audit 2005-06, BHIVA Audit and Standards Sub-Committee 2006, www.bhiva.org

9. Missed opportunities to detectchronic HIV infection? UK Fig 11 1Sullivan et al. BMJ, 2005; 2Ottewill, BHIVA 2006; 3Burns, BHIVA 2006

10. Missed opportunities to detectprimary HIV infection? Fig 12 • Brighton study: almost all MSM with pharyngitis, fever, rash • HCWs frequently not aware of patient’s sexual orientation • Significance of PHI in driving onward transmission • infectiousness • sexual behaviour 1Shacker, Ann Int Med 1996; 2Weintrob, Ann Int Med 2003; 3Sudarshi, BHIVA 2006

11. Fig 13 • “Pubmed” search; 2000-2007 • “late” or “missed” or “opportunity” “diagnosis” “HIV” “AIDS” • 421 entries • 59 consistent with them Informing clinicians about“Missed HIV” 83% of publications about late HIV diagnosis appeared in HIV/STD/ID/public health journals

12. Missed opportunities? Chronic Infection: • Secondary Care • Brighton: 62% of late diagnoses had been seen in secondary care in previous 2 years; 26% with HIV related problem1 • Primary Care • Brighton: 80% of late diagnoses had been seen in primary care in previous 2 years; 60% with HIV related problem1 • Accident and Emergency • Brighton: 2.5% of those with symptoms consistent with primary HIV had undiagnosed infection2 Primary HIV Infection: • 71% symptomatic; 51% seen in healthcare; 56% diagnosed – 19% of total3 • 1/680 men aged 18-50 with symptoms of PHI were seroconverting: ?not being blood-tested?2 1Ottewill M et al. BHIVA 2006; 2Nambiar K et al. BHIVA 2008 3 Sudarshi D et al. Sex Transm Infect 2008

13. Undiagnosed HIVand onward transmission Fig 14 100% 54 25 90% 80% 54 (70) (30) 70% 60% 50% 75 40% 30% 20% 46 10% 0% Undiagnosed or diagnosed HIV New HIV Diagnoses Marks et al. AIDS 2006

14. Effect of knowing HIV statuson sexual behaviour • Meta-analysis of 11 analyses of sexual behaviour • 6 compared HIV+ “aware” versus HIV+ “unaware” • 5 compared pre- and post- HIV seroconversion • All looked at self-reported rates of unprotected anal or vaginal intercourse • UAV 53% (CI 45-60%) lower in those aware versus unaware of HIV+ status • If only considering where partner HIV-, 68% (CI 59-76%) Marks et al. JAIDS 2005

15. Summary • Earlier diagnosis decreases: • morbidity • mortality • onward transmission • Routine/opt-out testing is acceptable to patients • Good practice - not to offer a test might be considered negligent • Pressure from specialists/CMO

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