Tackling HIV Testing

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Case 13
80 year-old White UK male Lived with
wife Living in urban area in England
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Case 13 May 2007

• Admitted via GP with
• Acute confusion
• History of recent weight loss
• Unwell for 10 months
• Reduced mobility
• One episode of urinary incontinence
• ? malignancy

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Case 13 PMH
TURP 1996 Chest infection 2000 Chest infection
2002 Fungal nail infection 2006 Glaucoma 2006
Pacemaker fitted 2006 - noted to have mass in
right side of neck
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Case 13 May Sept 2007

• OE
• Obvious wasting
• Mass in right side of neck, (biopsy result from
  previous week inconclusive)
• Rest of exam normal

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Case 13 May Sept 2007

• Investigations
• Lymphocyte count 0.9
• Na 124
• Quantiferon negative
• CT inflammatory mass

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Case 13 May Sept 2007

• Further investigations
• Repeat biopsy-atypical AAFBs
• Referred to ID
• Started on TB meds
• Noted to have oral candida

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Case 13 May Sept 2007

• On questioning
• Disclosed sexual contact in Thailand in 1990
• - male and female partners
• HIV test positive
• CD4 70

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Case 13 May Sept 2007

• Further course of illness
• Started on antiretrovirals and PCP prophylaxis
• CD4 210 after 3/12 treatment
• Remained confused
• - ? AIDS related dementia
• Unable to discharge home
• Discharged to nursing home
• Died 2008

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Case 13 summary
1996 Admitted for surgery - TURP 2000 Seen for
chest infection 2002 Seen for chest
infection 2006 Seen for fungal nail
infections 2006 Seen for glaucoma 2006 Admitted
for surgery pacemaker - mass on right side of
neck noted 2007 Admitted via GP with - 10
month history weight loss, dementia,
lymphopenia high risk sexual contact in high
prevalence area HIV diagnosed oral candida,
TB CD4 70 Inpatient for 4 months Nursing home
for 9 months
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Q At which of his healthcare interactions could
HIV testing have been performed?

• When he was admitted for TURP?
• When he was seen for recurrent chest infections?
• When he was found to have fungal nail infections?
• When he was diagnosed with glaucoma?
• When he was admitted to have a pacemaker fitted?
• When he was admitted with a 10-month history of
  unexplained weight loss and found to have
  dementia and lymphopenia?
• Should he 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
Source Health Protection Agency, www.hpa.org.uk
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Who to test?
Source UNAIDS Global Report 2008, www.unaids.org
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Who to test?
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Who to test?
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At least 5 missed opportunities! If current
guidelines used, HIV could have been diagnosed 7
years earlier
1996 Admitted for surgery - TURP 2000 Seen for
chest infection 2002 Seen for chest
infection 2006 Seen for fungal nail
infections 2006 Seen for glaucoma 2006 Admitted
for surgery pacemaker - mass on right side of
neck noted 2007 Admitted via GP with - 10
month history weight loss, dementia,
lymphopenia high risk sexual contact in high
prevalence area HIV diagnosed oral candida,
TB CD4 70 Inpatient for 4 months Nursing home
for 9 months
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Learning Points

• This patient appeared to be at low risk of HIV
  and presented with problems common in older
  people
• With no behavioural risk factors in the initial
  medical history, the otherwise excellent medical
  teams looking after him did not think of HIV even
  when the diagnosis seems obvious with hindsight
• He had numerous investigations and a nursing home
  stay, causing him and his family much distress
  and costing the NHS thousands of pounds
• 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 weight loss, dementia or
  lymphopenia 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 enquiries_at_medfash.bma.org.uk or
020 7383 6345
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