Mr X and Mr Y 1 Case 4: July 2007

26 year-old Caucasian man ‘Mr X’ 2

Case 4: July 2007 Presents to ED at 18:00 with: 1-day history of: maculopapular rash to chest, face, arms and legs 3-day history of: headache neck stiffness photophobia diarrhoea and vomiting arthralgia 3

Case 4: July 2007 OE: Pyrexia 39.8 o C Maculopapular rash over face, chest, limbs Photophobic, no overt meningism Routine bloods unremarkable CT head / LP NAD Treated to cover bacterial meningitis Clinically improved and discharged home No HIV test performed 4

Case 4: July year-old British gay male ‘Mr Y’ 5

Case 4: July 2008 Presents to ED with: Headache Neck stiffness Fever Maculopapular rash on face, chest, limbs Nausea, vomiting Cervical lymphadenopathy 6

Case 4: July 2008 History: Last sexual contact: –Regular Male Partner of 3 months (no condoms) Previous contacts: –Casual Male Partner 5 months ago (condoms) –Casual Male Partner 8 months ago (condoms) HIV-1 antibody test negative 3 months earlier 7

Case 4: July 2008 Investigations: Routine bloods unremarkable HIV-1 antibody: weakly positive HIV-1 antibody (detuned): suggestive of infection within 6 months HIV RNA viral load 1,000,000 copies/ml CD4 count 699 (9%) 8

Case 4: summary Both: viral type illness with meningism and rash Mr Y’s Regular Male Partner of 3 months = Mr X Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion 9

Q: When could HIV testing have been recommended in this scenario? 1.When Mr X was admitted with aseptic meningitis without any apparent risk factors? 2.When Mr Y was admitted with aseptic meningitis with a history of sex with other men? 3.Should they have been referred on discharge to GUM to see a trained counsellor before HIV testing? 10

Who can test? 11

12 Who can test?

Who to test? 13

Who to test? 14

Who to test? 15

Q: What kind of tests should have been used to diagnose seroconversion illness? 1.Rapid test? 2.3 rd generation antibody test? 3.4 th generation antigen/antibody test? 4.PCR (viral load)? 16

Which test to use? 17

Case 4: summary Both: viral type illness with meningism and rash Mr Y’s Regular Male Partner of 3 months = Mr X Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion 18 Was Mr Y’s HIV infection preventable?

Primary HIV Infection is easily missed – have a low index of suspicion on presentation of PUO, meningism and rash in adults During PHI viral load is extremely high making the patient highly infectious Some patients may not disclose that they have put themselves at risk of HIV infection in the past A perceived lack of risk should not deter you from offering a test when clinically indicated 19 Learning Points

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 Primary HIV Infection is a unique opportunity to diagnose HIV as the patient’s next HIV-related presentation may be at a late stage of infection 20 Key messages

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