The case for increasing HIV testing in all medical settings 1

2 <45 years at seroconversion >45 years at seroconversion Estimated cumulative mortality Time since seroconversion (years) All-cause mortality pre-1996 and (sexual exposure only) Pre-1996 (HIV infected) (HIV infected) (general uninfected) Porter K, et al. 15th CROI 2008 Abstract 14 Fig 1 Fig 2

Estimated prevalence of HIV infection in adults* in the UK at the end of Aged inclusive - excludes those who have died during the year Fig 3

Estimated late diagnosis 1 of HIV infection by prevention group, UK: Fig 4

Estimated prompt 1 and late 2 HIV diagnosis 3 in MSM with associated short-term mortality 4 : UK ( ) 5 Fig 5 Fig 6

Estimated prompt 1 and late 2 HIV diagnosis 3 in black Africans and Caribbeans with associated short-term mortality 4 :UK ( ) 6 Fig 7 Fig 8

7 Cost of care after HIV diagnosis in Canada Gill WJ, Krentz HB. Poster 12C th European AIDS Meeting, Madrid, 24–27 October 2007 Mean cost (C$) Fig 9 TotalInpatientOutpatientARV drugs Cost category <1 year>1 year<1 year>1 year<1 year>1 year<1 year>1 year CD4 <200 CD4 >200

BHIVA Audit 2006: Scenario leading to death 8 Source: Mortality audit , BHIVA Audit and Standards Sub-Committee 2006, Top bars: reclassified during audit Bottom bars: as initially reported Fig 10

Missed opportunities to detect chronic HIV infection? UK Location (Time Period) DefinitionGroup% presenting to any health care % HIV related UK (BHIVA) CD4 < 2002° CareN/A17% within 12 months Brighton AIDS at diagnosis 2° Care62%26% Brighton AIDS at diagnosis 1° Care80%60% London (SONHIA) AIDS or CD4 <200 1° Care75% in primary care in last 2 years N/A 9 1 Sullivan et al. BMJ, 2005; 2 Ottewill, BHIVA 2006; 3 Burns, BHIVA 2006 Fig 11

Missed opportunities to detect primary HIV infection? Location% symptomatic % seen in HC Diagnosis madecomments US 1 89%88%26% (10% of total) 15% hospitalised ! US 2 n/a52%17%most seen > 3 times Brighton 3 71%51%56% (19% of total) GP >> A&E > others 10 Brighton study: almost all MSM with pharyngitis, fever, rash HCWs frequently not aware of patient’s sexual orientation Significance of PHI in driving onward transmission infectiousness sexual behaviour 1 Shacker, Ann Int Med 1996; 2 Weintrob, Ann Int Med 2003; 3 Sudarshi, BHIVA 2006 Fig 12

Informing clinicians about “Missed HIV” “Pubmed” search; “late” or “missed” or “opportunity” “diagnosis” “HIV” “AIDS” 421 entries 59 consistent with them 11 Fig 13 83% of publications about late HIV diagnosis appeared in HIV/STD/ID/public health journals

Missed opportunities? Chronic Infection: Secondary Care –Brighton: 62% of late diagnoses had been seen in secondary care in previous 2 years; 26% with HIV related problem 1 Primary Care –Brighton: 80% of late diagnoses had been seen in primary care in previous 2 years; 60% with HIV related problem 1 Accident and Emergency –Brighton: 2.5% of those with symptoms consistent with primary HIV had undiagnosed infection 2 Primary HIV Infection: –71% symptomatic; 51% seen in healthcare; 56% diagnosed – 19% of total 3 –1/680 men aged with symptoms of PHI were seroconverting: ?not being blood-tested? Ottewill M et al. BHIVA 2006; 2 Nambiar K et al. BHIVA Sudarshi D et al. Sex Transm Infect 2008

Undiagnosed HIV and onward transmission 13 Marks et al. AIDS % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Undiagnosed or diagnosed HIV New HIV Diagnoses 46 (70) (30) 54 Fig 14

Effect of knowing HIV status on sexual behaviour Meta-analysis of 11 analyses of sexual behaviour –6 compared HIV+ “aware” versus HIV+ “unaware” –5 compared pre- and post- HIV seroconversion –All looked at self-reported rates of unprotected anal or vaginal intercourse UAV 53% (CI 45-60%) lower in those aware versus unaware of HIV+ status –If only considering where partner HIV-, 68% (CI %) 14 Marks et al. JAIDS 2005

Summary Earlier diagnosis decreases: –morbidity –mortality –onward transmission Routine/opt-out testing is acceptable to patients Good practice - not to offer a test might be considered negligent Pressure from specialists/CMO 15

16 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: or