HIV CNS’s & Health Advisors 24th November 2017 Case Studies HIV CNS’s & Health Advisors 24th November 2017

Nov 2013 – Pneumococcal sepsis Dec 2015 – Dental operation Case study 1 Hospital admissions: Nov 2013 – Pneumococcal sepsis Dec 2015 – Dental operation Sept 2017 – Oral candidiasis, Liver abscess. 42 yr old heterosexual Black female. Social History Ongoing issues: Advancing HIV infection (Due to non-compliance) Denial Isolation Stigma Strong Faith beliefs Tested positive ante-natally Presented with: Oral thrush, rash, pyrexia. HIV Positive January 2003 CD4 - 85 VL – 735, 523 -From Congo been positive for 20 years. Witnessed HIV positive pple who survived for long time without ARVs & believes they surviving by prayer. This has shaped her beliefs in her faith to only trust God to save her. 1st 3 children HIV Negative, despite mothers non-adherence in pregnancy to HIV medication 20.5.2010 4th child HIV POSITIVE. Court order as failure to give child her HIV therapy. Non-adherence. Disengaged. Letters to GP. 2015 Dental Operation dependent on CD4. Pt re-commenced ARVs’. Patient pattern ‘to only engage due to symptoms’ therefore ARVs’ short course for symptomatic relief. 2017 taking antibiotics for liver abscess but not ARVs’. Discharged home with palliative care for management of symptoms “without admission to hospital”. HCPs’ to remember Patient’s choice Not to take ARVs’ and to respect their wishes. Patient referred palliative care Partner confirmed HIV negative on 17.04.2009 X3 children negative X1 child HIV positive born 20.5.2010 (Positive child in foster care) Partner notification ongoing

17.9.17 – A&E – SOB, widespread rash, diarrhoea (GP had given piriton and steroids) ?allergy to CTPA contrast ?infectious mononucleosis ?legionella – admitted 18.9.17 “no clear explanation for condition & Hypoxia” Case study 2 19.9.17 ward round – CT review ?PCP D/W ID team suggested HIV test and sputum PCR for PCP Commence cotrimoxazole Consider a bronchoscopy 28 yrs caucasian builder, female partner, baby girl 1yr 14.9.17 – A&E increasing SOB, hypoxic (GP treated with ABX &Steroids) ?PE – CTPA some ground glass opacity? Inflammatory change (comment on report that PCP had been discussed) – CXR – bilat. enlarged lymph nodes Discharged home advised to improve inhaler technique 21.9.17 Cotrimoxazole commenced- SB ID team noted pharyngeal candida HIV Positive 22.9.17 SB Health advisor

Sexual history prompted HIV screen. 12.10.2005 – HIV POSITIVE CD4 – 61 Case Study 3 Sexual history prompted HIV screen. 12.10.2005 – HIV POSITIVE CD4 – 61 VL - 474, 000 Commence ARVs’ 7.11.2005 47 year old, African, heterosexual male. Social History Issues post diagnosis: Stigma Isolated Depression Immigration Adherence 11.10.2005 GP referral acute chronic renal failure. Investigations: KUB U/S = small kidneys Egfr = 28 Serum creatinine - 1697 Commenced renal dialysis (3 x a week) 2004 -Diagnosed with Chronic Renal failure -Emigrated from Malawi in 2000. Registered with GP and diagnosed with hypertension. DNA’d GP appointments for follow up of BP & U &Es. -Reffered & admitted to QE HDU with chronic kidney failure. Tested as high risk group. Huge migration early 2000. --HIV + . Shocked & upset to “Death sentence” & feared would die soon. -Patient given special leave to stay in the country for haemodialysis + on active transplant list & HIV meds. -Since transplant adherence with attending FU appointment for Renal transplant & HIV ongoing. As HCPs’ we know dialysis alone, can feel like institutionalisation for patients’ due to numerous appointments until transplant! -He has since been given leave to remain & travelled to Malawi to see family. -Living a normal life & currently looking for a girlfriend! 16.3.2016 - Renal Transplant Partner notification

Oral Thrush - ID , Liver screen (inc. Hep, HIV) USS req. Case Study 4 Clinical Signs Deranged LFT’s Oral Thrush - ID , Liver screen (inc. Hep, HIV) USS req. 56 yrs, Caucasian, from Sutton Coldfield, community phlebotomist. ? Sepsis, IV ABX No HIV exposure identified 10 day hx fevers, sore throat, rash, treated by GP for tonsilitis CD4 Count 134 Viral Load 190,89332

Partner Notification ……. Case Study 4- Partner CD4 156 Viral Load 34,2575 Partner Notification …….

Case Study 5 Pt admitted declining HIV testing in past due to fear. 59 yr old MSM male To GP with lesions on arm- reassured and sent away HIV Positive KS lesions on arms Different GP- lethargy, low mood, lymphocytosis – PMH- genital warts, toxoplasmosis, syphilis- HIV test suggested

21 year old female diagnosed @ 18 Case Study 6 21 year old female diagnosed @ 18 Attends clinic and is found to be pregnant Good CD4, low-ish VL Does not attend appointments for HIV or Antenatal care as arranged Care leaver, victim of CSE, ADHD, substance abuse, vulnerable ++ But did start medication and VL <40 Rarely attends. Normally when has symptomatic STI’s Safeguarding & S Work involved. Baby HIV neg, currently in foster care Never managed any PN