Transcript Tackling HIV Testing Case 1

Case 1
43 year-old white woman from UK
Living in London
Divorced
No children
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Case 1: March 2007
Admitted via Gastroenterology
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Fatigue
Anorexia
Weight loss
Night sweats
Investigations:
• Anaemia Hb 6.5
• OGD (1) bleeding gastric ulcer: injected
• OGD (2) ulcer healed; ?oesophageal candida
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Case 1: PMH
1990’s
Seen in GP for:
depression, hypertension,
hypercholesterolemia, DM
Known pre-proliferative retinopathy;
nephropathy
1999
TB “following a trip to Caribbean”
2003
MI, stent
2006
MI, stent
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Case 1: April 2007
Week 1:
• Respiratory compromise
• CXR: Bilateral pleural effusions
• Parenchymal disease
Week 2:
• HIV test positive
Week 4:
• Bronchoscopy: PCP on BAL
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Case 1: April – June 2007
ITU – 45 day stay:
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PCP: BiPAP
Chest drains for bilateral effusions
Renal failure: haemofiltered
Intercurrent sepsis x 3
Heparin-induced thrombocytopenia
Oesophageal candidiasis
HIV: ARVs started end May 2007
Case 1: June – August 2007
• HIV: CD4 27 (14%) VL 283,301
CD4 at 4 months 202 (19%); VL 167
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DM control
Renal impairment and fluid overload/ ascites
Hypertension control
Post ITU rehabilitation (voluntary sector)
Discharged home (5 months after initial
admission)
Case 1: summary
1994
1996
1999
2003
2006
March 2007
GP: BP, cholesterol, depression
GP: Type 1 diabetes
Respiratory OPD, TB
Medical admission, MI
Medical admission, MI
Admitted via Gastroenterology
oesophageal candida, weight loss
April 2007
Respiratory compromise:
HIV diagnosed: PCP: CD4 27: VL 283,301
Inpatient 19 weeks, rehabilitation 3 weeks
Includes 45 days on ITU
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Q: At which of her healthcare interactions
could HIV testing have been performed?
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When she was seen in the diabetic clinic?
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When she was diagnosed with TB?
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When she was admitted with her MIs?
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When she was diagnosed with oesophageal candida?
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Should she have been referred to GUM to see a
trained counsellor before HIV testing?
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Who can test?
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Who to test?
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Who to test?
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Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
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Source: Health Protection Agency, www.hpa.org.uk
Who to test?
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Up to 6 missed opportunities!
If current guidelines used, HIV could have been
diagnosed at least 9 years earlier
1994
1996
1999
2003
2006
March 2007
GP: BP, cholesterol, depression
OPD: Type 1 diabetes
Respiratory OPD, TB
Medical admission, MI
Medical admission, MI
Admitted via Gastroenterology
oesophageal candida, weight loss
April 2007
Respiratory compromise:
HIV diagnosed: PCP: CD4 27: VL 283,301
Inpatient 19 weeks, rehabilitation 3 weeks
Includes 45 days on ITU
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Learning Points
• This patient appeared to be at low risk of HIV (but had
been treated for an AIDS-defining condition 9 years
previously)
• Because of this the otherwise excellent medical teams
looking after her did not think of HIV even when the
diagnosis seems obvious with hindsight
• She had numerous investigations and a long ITU stay,
causing her much distress and costing the NHS
thousands of pounds – an HIV test in 1999 would have
avoided that
• A perceived lack of risk should not deter you from
offering a test when clinically indicated
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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
• HIV screening should be a routine test on presentation
of PUO, chronic diarrhoea or weight loss of otherwise
unknown cause
• Some patients may not disclose that they have put
themselves at risk of HIV infection in the past
• Opt-out and routine HIV testing overcomes barriers for
staff and patients
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Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
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