1. HIV Testing Who When and How Adrian Palfreeman Reader in Infection University of Leicester (Head of service / Consultant)

2. The problem 103,700 HIV +ve in UK 17% unaware Significant burden of late presentation Opportunity to prevent transmission Barriers to testing – Patients – Society – Doctors

3. 3 HIV is a treatable infection and should be considered in the differential diagnosis in many clinical scenarios

5. Richmond House 79 Whitehall London SW1A 2NS 13 September 2007 Dear Colleague Improving the detection and diagnosis of HIV in non-HIV specialties including primary care 1.We are writing to ask for your help in combatting the continuing threat of HIV infection to the public health. A special effort on your part would do much to improve the situation. SIR LIAM DONALDSON PROFESSOR CHRISTINE BEASLEY CHIEF MEDICAL OFFICER CHIEF NURSING OFFICER

8. Who can offer testing? Any competent healthcare professional Pre-test discussion – Benefits of testing – Obtain informed consent – Determine how results will be given – Discuss other issues raised by patient Optional use of written leaflets Written consent unnecessary Ref. Consent: patients and doctors making decisions together GMC 2008

9. Where should universal screening be offered? Universal screening – GUM – TOP and antenatal clinics – Drug dependency programmes – Blood and organ donation – Asylum Health – Outreach programmes with at-risk populations CSW MSM

10. Who should be offered a test? : All individuals known to be from a high prevalence country Men that have disclosed sexual contact with other men All men and women who report sexual contact with individuals from areas of high HIV prevalence, abroad or in the UK. All general medical admissions and GP new registrations from a population where the local diagnosed HIV prevalence exceeds 2 in 1000 Anyone with an HIV indicator condition

11. What is indicator condition based HIV testing? Indicator conditions are conditions known to be, or believed to be, associated with an excess risk of being HIV- positive There is a paucity of evidence of prevalence of previously undiagnosed HIV in indicator conditions Indicator condition based testing may be an effective HIV testing strategy Routine HIV testing is cost effective when the undiagnosed HIV prevalence in the target group >0.1%

12. HIV Indicator Diseases Across Europe Study – Phase 2 Open call to European centres Routine offer of HIV test to patients (18-65 yrs) presenting with indicator condition Simple demographic data collected; additional data items for those newly diagnosed HIV+ Primary endpoint: demonstration of previously undiagnosed HIV infection >0.1% in each indicator condition (IC) Projected n=11 000 Open 2012 - 2014

13. Enrolment 150 surveys were performed, across 42 clinical centres in 20 countries across four regions of Europe 10 139 patients were enrolled Excluded participants: 668 Total of 9471 participants Recruitment by regionNumber enrolled% Total9471100 South5005.3 Central94210.0 North229724.3 East573260.5

14. HIV prevalence by indicator condition 95% CI > 0.1 95% CI < 0.1 Tested7373440172218818417512991126133958827653144 HIV+739163261241613 4100 0.1% and LL 95%CI>0.1%

15. 15 Clinical Indicator Diseases Respiratory: Pneumonia (atypical, recurrent) Tuberculosis Pneumocystis Pneumonia

16. 16 Clinical Indicator Diseases Dermatology: Shingles (atypical, multidermatomal, recurrent) Seborrhoeic Dermatitis Psoriasis Kaposi’s Sarcoma

17. 17 Clinical Indicator Diseases Haematology: Any unexplained blood dyscrasias – thrombocytopenia – neutropenia – anaemia

18. 18 Clinical Indicator Diseases Neurology: Space Occupying Lesions (Toxo/other abscess/Lymphoma) Dementia Peripheral Neuropathy

19. 19 Clinical Indicator Diseases Other: Lymphadenopathy Glandular Fever like illness Pyrexia of Unknown Origin Weight Loss Fatigue Chronic Diarrhoea Any STI

20. 20 Clinical Indicator Diseases Malignancy: Lymphoma Testicular tumour Cervical dysplasia / CIN / Cervical Cancer Anal dysplasia / AIN / Anal Cancer

21. BHIVA Audit of 2008 Guidelines Indicator conditions for testing Between the start of 2008 and testing positive: – 410 (36.5%) patients had one or more indicator condition as listed in guidelines – 632 indicator conditions

22. Frequency of indicator conditions

23. Test offer at time of indicator condition

24. Missed opportunities for earlier diagnosis As reported by the respondents: – 280 (25.2%) of patients had had a missed opportunity for HIV testing before the actual first positive test. – n=93 in Primary Care – n=53 in Medical Outpatients

26. How to get the undiagnosed tested What worked in GUM? Setting a national target –60% uptake of HIV testing by 2007 Inclusion of HIV testing as part of routine STI screen –Opt-out strategy Discarding need for routine in-depth pre-test counselling –Use of leaflets to give information about test

27. DH funded testing pilots 3 hospital based – HINTS – Brighton – Leicester 3 community based – South London X2 – Sheffield 3 GP based – Brighton – South London – (RIVA 2 East London)

28. Leicester Large city in east midlands HIV prevalence 3.5/1000 (2008) Significant ethnic diversity A+E dept at Leicester Royal Infirmary busiest outside London AMU has 70,000 admissions a year

29. Project Test all admissions to LRI 16-60 on AMU A+E not possible- 4 hour wait Most bloods taken in A+E- 70% then discharged same day Working group established Consultants informed by email Grand round presentation

30. Project Patents on AMU have bloods taken by clinical aides when directed- HIV test added with info sheet in 5 languages No extra resources needed other than underwriting lab costs Juniors seen at induction Frequent reminded visits by GU to AMU +ves linked promptly into care

32. Leicester AMU results 2008 approx 5 HIV tests per month HIV testing guidelines launched, Grand round presentation of missed case 2009 15 tests a month 2010 Testing pilot average of 80 tests a month 4 new +ves found in 2009 10 new +ves found in 2010 +ve Rate of 1% Potentially many more missed so much work still to be done

33. Tom, a 32 year old teacher presents with 1 week fever, lethargy, sore throat & rash. What does your differential diagnosis include? Tom: Fever and a rash

34. Tom, a 32 year old teacher presents with 1 week fever, lethargy, sore throat & rash. On direct questioning he discloses unprotected anal intercourse with 5 casual male partners in last 3 months What does your differential diagnosis include? Tom: Fever and a rash

35. Tom: Fever and a rash Differential HIV seroconversion Secondary syphilis Hepatitis A, B, C CMV EBV

36. 36 Opportunity for PHCT to diagnose It’s not always easy … as non specific. Symptoms : febrile, flu-like, lethargy, sore throat, rash, swollen glands. If history of UPSI _ you need to ask. ( ♂♂ ) Individual and Public Health Benefit Image: Terence Higgins Trust Primary HIV / seroconversion

37. Thanks and good luck