Case 8 Infectious Diseases, General Medicine

Report
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)
1
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
2
Case 8: late July 2009
Presented to GP with:
• Flu-like illness
(presumed H1N1 treated with Tamiflu)
• Herpes Zoster left trunk
Offered HIV test
•
•
•
•
3
HIV positive
CD4 189
Viral load 90,000
Hb 8.7
Case 8: summary
2001
From 2004
2006
2007
2008
2009
4
Registered with GP
Seeing GP for hypertension
Pre-op screening - arthroscopy
Admitted for PUO/suspected malaria
and anaemia
GP notes >10 kg weight loss since Nov
2007
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?
1. When he first registered with his GP?
2. When he saw GP for hypertension?
3. When he was admitted by the orthopaedic
team for arthroscopy?
4. When he was admitted for PUO/malaria and
noted to have anaemia?
5. When his GP noted his >10kg weight loss?
6. Should he have been referred to GUM to see a
trained counsellor before HIV testing?
5
Who can test?
6
Who to test?
7
Who to test?
8
Who to test?
9
Who to test?
2008 Report on the
global AIDS epidemic
HIV prevalence (%) in adults (15–49) in Africa, 2007
10
Who to test?
11
Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
12
Source: Health Protection Agency, www.hpa.org.uk
At least 5 missed opportunities!
If current guidelines used, HIV diagnosed 8 years
earlier
2001
From 2004
2006
2007
2008
2009
13
Registered with GP
Seeing GP for hypertension
Pre-op screening - arthroscopy
Admitted for PUO/suspected malaria
and anaemia
GP notes >10 kg weight loss since Nov
2007
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
14
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
15
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
16

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