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Tackling HIV Testing Case 1

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Tackling HIV Testing Case 1
Case 1
43 year-old white woman from UK
Living in London
Divorced
No children
1
Case 1: March 2007
Admitted via Gastroenterology
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•
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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
2
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
3
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
4
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
7
Q: At which of her healthcare interactions
could HIV testing have been performed?
1.
When she was seen in the diabetic clinic?
2.
When she was diagnosed with TB?
3.
When she was admitted with her MIs?
4.
When she was diagnosed with oesophageal candida?
5.
Should she have been referred to GUM to see a
trained counsellor before HIV testing?
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Who can test?
9
Who to test?
10
Who to test?
11
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?
13
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
14
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
16
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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