Late Diagnosis of HIV in Northern Ireland Walker E, Todd SEJ, Rafferty P, Donnelly CM, Emerson CR, Dinsmore WW, Quah SP, McCarty EJ Department of Genito-Urinary Medicine, Belfast HSC Trust, Belfast, UK.

Background Over 800 patients in NI with HIV Around new registrations/year (newly diagnosed/transfer of care) Late diagnosis of HIV remains a problem 10-fold increased risk of death in year following diagnosis Deaths as diagnosed too late – treatment ineffective Near-normal life expectancy if diagnosed promptly Early diagnosis results in reduced onward transmission Large numbers unaware of diagnosis

BHIVA Guidelines (2008) Facilitate increase in testing across all healthcare settings Aim to benefit both individual and public health Encourage ‘normalisation’ of testing New diagnoses linked to specialist care Awareness of clinical indicator diseases, as well as opportunistic screening based on prevalence data

BHIVA National Audit (2010) Retrospective audit – 1112 patients Newly diagnosed patients 52.2% had late diagnosis 62.6% diagnosed in traditional settings 33% non-traditional Quarter of patients had missed opportunity for earlier diagnosis

HIV in UK: 2014 Report (PHE) 42% diagnosed late in 2013 (57% in 2004) 24% CD4 <200 Late diagnoses highest among heterosexual men/women Smallest proportion among MSM Number of MSM diagnosed late remained stable More frequent testing among MSM Over 50 more likely to have late diagnosis (58% vs 39%)

Who should test? Universal testing: GUM or sexual health clinics Antenatal services Termination of pregnancy services Drug dependency programmes Healthcare services for pts with TB, hep B and C and lymphoma Consider in (where HIV prevalence > 2/1000): All men/women registering at GP All general medical admissions

Routinely offered/recommended: All patients where HIV enters the differential diagnosis All patients diagnosed with an STI All sexual partners of men and women known to be HIV positive All men who have disclosed sexual contact with other men All female sexual contacts of men who have sex with men All patients reporting a history of injecting drug use All men and women known to be from a country of high HIV prevalence (>1%) All men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence Also routinely performed in: blood donors dialysis patients organ transplant donors and recipients.

Clinical Indicator Diseases AIDS-defining conditions Respiratory TB PCP Neurology Cerebral toxoplasmosis Primary cerebral lymphoma Cryptococcal meningitis Progressive multifocal leucoencephalopathy Other conditions where HIV testing should be offered Bacterial pneumonia Aspergillosis Aseptic meningitis/encephalitis Cerebral abscess Space occupying lesion of unknown cause Guillain–Barré syndrome Transverse myelitis Peripheral neuropathy Dementia Leucoencephalopathy

AIDS-defining conditions Dermatology Kaposi’s sarcoma Gastroenterology Persistent cryptosporidiosis Other conditions where HIV testing should be offered Severe/recalcitrant seborrhoeic dermatitis Severe/recalcitrant psoriasis Multidermatomal or recurrent herpes zoster Oral candidiasis Oral hairy leukoplakia Chronic diarrhoea of unknown cause Weight loss of unknown cause Salmonella, shigella or campylobacter Hepatitis B infection Hepatitis C infection

AIDS-defining conditions Oncology Non-Hodgkin’s lymphoma Gynaecology Cervical cancer Haematology Other conditions where HIV testing should be offered Anal cancer or anal intraepithelial dysplasia Lung cancer Seminoma Head and neck cancer Hodgkin’s lymphoma Castleman’s disease Vaginal intraepithelial neoplasia Cervical intraepithelial neoplasia Grade 2 or above Any unexplained blood dyscrasia

AIDS-defining conditions Ophthalmology CMV retinitis ENT Other Other conditions where HIV testing should be offered Infective retinal diseases including HSV and toxoplasma Any unexplained retinopathy Lymphadenopathy of unknown cause Chronic parotitis Lymphoepithelial parotid cysts Mononucleosis-like syndrome (primary HIV) PUO Any lymphadenopathy of unknown cause Any STI

Our Audit Retrospective chart analysis July 2013 – June total new diagnoses 45 late diagnoses (CD4 < 0.35 x 10 9 /L) 31 severe immunocompromise (CD4 < 0.20 x 10 9 /L) 34 men, 11 women Age range 21 years to 65 years; mean age 44 4 patients attended GUM in past (9%) 11 patients had previous HIV test (24%) 20 % diagnosed by GUM Remainder diagnosed via a range of specialties

Ethnicity

Mode of acquisition

Diagnosis by Specialty

Previous Investigations 25/45 (57%) attended a number of specialties for Ix prior to HIV diagnosis Wide range of tests carried out

Investigations

Clinical Indicator Disease 38/45 (84%) had one or more indicator diseases 20/45 (44%) had one or more AIDS defining illness 14/45 (31%) had PCP 20/45 (44%) had unexplained blood dyscrasia

AIDS defining Conditions

Other Conditions

Outcomes 20/45 (44%) were inpatients when diagnosis was made Average inpatient stay 19 days 5 patients (11%) had ICU/HDU admission 3/45 (7%) of patients died 41/45 (91%) commenced ARV

Conclusions Late diagnosis of HIV an increasing problem – 59% of new diagnoses in NI (compared to 42% in UK) 41% diagnosed very late (24% in UK) Results in increased burden of disease with lengthy inpatient stays High proportion of patients diagnosed in non-GUM settings – increased provision of testing Majority of patients had one or more clinical indicator diseases Opportunities for earlier diagnosis still being missed