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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). Case 8: PMH. 2001 Registered with GP 2004 Hypertensive – treatment started
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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)
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 >10 kg weight loss noted Said he had been trying to lose weight as previously overweight
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
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 >10 kg weight loss since Nov 2007 2009 Seen by GP for Herpes zoster HIV diagnosed: CD4 189, VL 90,000
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 >10kg weight loss? • Should he have been referred to GUM to see a trained counsellor before HIV testing?
Who to test? 2008 Report on the global AIDS epidemic HIV prevalence (%) in adults (15–49) in Africa, 2007
Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk
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 >10 kg weight loss since Nov 2007 2009 Seen by GP for Herpes zoster HIV diagnosed: CD4 189, VL 90,000
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
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 >1/1000 as it has been shown to be cost-effective
Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345