Case 5

1
Case 5

• 45 year-old woman
• From Sub-Saharan Africa
• Lives in London
• In UK 10 years

2
Case 5 PMH

• 1998 Registered with GP
• 2006 Seen by GP for hypertension
• 2007 Seen by Dermatology OPD for Molluscum
  contagiosum

3
Case 5 June 2008

• Referred by GP to Gynaecology OPD
• Multiple vulval warts
• On direct questioning also admitted to
• weight loss
• dysphagia
• blurred vision

4
Case 5 June 2008

• OE
• Multiple pigmented vulval lesions
• Molluscum contagiosum
• White patches in the mouth

5
Case 5 June 2008

• Investigations
• Vulval lesions biopsied VIN1/2.
• Hb 12.1, WCC 4.4, lymphocytes 0.66
• HIV Antibody positive
• CD4 35 cells/mm3
• Viral load 700,000 copies/ml

6
Case 5 June 2008

• Further course of illness
• Referred to gynaecological oncologist for VIN
• OGD showed oesophageal candidiasis
• Fundoscopy revealed CMV retinitis
• Treated with
• Antiretrovirals (Truvada/Nevirapine)
• Oral septrin
• IV ganciclovir
• High dose fluconazole

7
Case 5 summary

• 1998 Registered with GP
• 2006 Seen by GP for hypertension
• 2007 Seen in Dermatology OPD with
• molluscum contagiosum
• 2008 Seen in Gynaecology OPD with
• weight loss, oral candida and vulval warts
• HIV diagnosed CMV retinitis
• CD4 35 VL 700,000

8
Q At which of her healthcare interactions could
HIV testing have been performed?

• When she registered with her GP?
• When she was seen by her GP for hypertension?
• When she was seen in Dermatology OPD?
• Should she have been referred to GUM to see a
  trained counsellor before HIV testing?

9
Who can test?
10
Who to test?
Who to test?
11
Who to test?
12
Who to test?
13
Rates of HIV-infected persons accessing HIV care
by area of residence, 2007
Source Health Protection Agency, www.hpa.org.uk
14
At least 3 missed opportunities! If current
guidelines used, HIV could have been diagnosed up
to 10 years earlier

• 1998 Registered with GP
• 2006 Seen by GP for hypertension
• 2007 Seen in Dermatology OPD with
• molluscum contagiosum
• 2008 Seen in Gynaecology OPD with
• weight loss, oral candida and vulval warts
• HIV diagnosed CMV retinitis
• CD4 35 VL 700,000

15
Who to test?
Source UNAIDS Global Report 2008, www.unaids.org
16
Learning Points

• This patient was at high risk of HIV as she comes
  from an area of high HIV prevalence
• She had had numerous contacts with medical
  services over 10 years
• She had previously presented on one recorded
  occasion with a condition closely associated with
  HIV infection
• Because of her nadir CD4 of 35 she has an
  increased risk of potential problems despite
  control of her HIV now
• She actually had an AIDS-defining condition at
  the time of diagnosis

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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
• 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 is
  gt1/1000 as it has been shown to be cost-effective

18
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