Case 5
45 year-old woman
From Sub-Saharan Africa
Lives in London
In UK 10 years
1
Case 5: PMH
1998
Registered with GP
2006
Seen by GP for hypertension
2007
Seen by Dermatology OPD for
Molluscum contagiosum
2
Case 5: June 2008
Referred by GP to Gynaecology OPD
• Multiple vulval ‘warts’
• On direct questioning also admitted to:
– weight loss
– dysphagia
– blurred vision
3
Case 5: June 2008
OE:
• Multiple pigmented vulval lesions
• Molluscum contagiosum
• White patches in the mouth
4
Case 5: June 2008
Investigations:
•
•
•
•
•
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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
Case 5: June 2008
Further course of illness:
•
•
•
•
Referred to gynaecological oncologist for VIN
OGD showed oesophageal candidiasis
Fundoscopy revealed CMV retinitis
Treated with
–
–
–
–
6
Antiretrovirals (Truvada/Nevirapine)
Oral septrin
IV ganciclovir
High dose fluconazole
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
7
Q: At which of her healthcare interactions
could HIV testing have been performed?
1. When she registered with her GP?
2. When she was seen by her GP for
hypertension?
3. When she was seen in Dermatology OPD?
4. Should she have been referred to GUM to see
a trained counsellor before HIV testing?
8
Who can test?
9
Who to test?
Who to test?
10
Who to test?
11
Who to test?
12
Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
13
Source: Health Protection Agency, www.hpa.org.uk
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
14
Who to test?
2008 Report on the
global AIDS epidemic
HIV prevalence (%) in adults (15–49) in Africa, 2007
15
Source: UNAIDS Global Report 2008, www.unaids.org
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
•
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She actually had an AIDS-defining condition at the time
of diagnosis
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 >1/1000 as
it has been shown to be cost-effective
17
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
enquiries@medfash.bma.org.uk
or 020 7383 6345
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