1. HIV TESTING IN NEWLY DIAGNOSED LYMPHOMAS IN NOTTINGHAM CITY HOSPITAL
HIV TESTING IN NEWLY DIAGNOSED LYMPHOMAS IN NOTTINGHAM CITY HOSPITAL. A RETROSPECTIVE ANALYSIS
Author:
Danai Papakonstantinou
Supervisors:
Dr Christopher Fox, Consultant Haematologist
Dr Pradhib Venkatesan, Consultant in Infectious Diseases

2. AUDIT OBJECTIVE
The aim of this audit is to define how many patients with newly diagnosed lymphomas have been tested for HIV at the time of their diagnosis in NCH between January-June 2010 with reference to UK National Guidelines for HIV testing.

3. INTRODUCTION

4. CLASSIFICATION FOR LYMPHOID MALIGNANCIES WHO (2008)
Mature B cell neoplasms
Mature T cell and NK neoplasms
Hodgkin’s lymphomas and
Post transplantation lymphoproliferative diseases

5. HIV ASSOCIATED LYMPHOMAS
Most common HIV associated lymphomas:
- Burkitt’s lymphoma
- Diffuse large B cell NHL.
Lymphomas specific in HIV positive patients :
- Primary effusion lymphoma (PEL) and its solid variants
- Plasmablastic Lymphoma of the oral cavity
- LBCL arising in Kaposi sarcoma herpesvirus (KSHV)–associated multicentric Castleman disease
HIV –asociated lymphomas and gamma-herpesviruses Carbone et al, BLOOD 2009

6. HAART era
Spectrum of diseases shifted from AIDS related to non AIDS related diseases.
Estimated SIR in HIV/AIDS individuals was 76.67( % CI) for NHL and ( % CI) for HL.
Prognosis for HIV associated lymphomas improved with chemotherapy & ARV drugs
Grulich et al. Incidence of cancers in people with HIV/AIDS compared with immunosupressed transplant recipients: a metanalysis Lancet 2007

7. HIV PREVALENCE IN U.K.
The Health Protection Agency reports that in 2010:
Estimated number of people with HIV infection in the UK up to 86,500 (Prevalence: 1.4 per 1000 people)
¼ unaware of their condition. (2009 findings)
6,630 new HIV diagnoses in the UK (2009)
New diagnoses among older adults (>50y old ) doubled between 2000 & 2009 and accounted for 13% of all diagnoses in 2009.
37 PCTs have HIV prevalence > 2.0 per 1000 population
Health Protection Agency HIV in the United Kingdom: 2010 Report

8. HIV PREVALENCE IN NOTTINGHAM
The prevalence of diagnosed HIV infection in the
Nottingham City PCT in 2009 was
2.35 per 1,000 population
Data from the Survey of Prevalent HIV Infections Diagnosed (SOPHID), Health Protection Agency, 2009.

9. HIV prevalence in lymphoma patients
Nottingham City PCT HIV prevalence 2.35/1000.
? Prevalence of HIV in lymphoma population in Nottingham
Many studies have shown higher prevalence of HIV in lymphoma patients compared to healthy individuals
e.g. a prevalence study of HIV antibodies in patients NHL in Lagos, Nigeria prevalence of HIV in NHL patients was 25% versus the prevalence in healthy routine blood donors which was 4.8%.
Akinsete et al Prevalence study of HIV antibodies in patients with non-Hodgkin's lymphoma (NHL) in Lagos, Nigeria.
Int Conf AIDS. 1998

10. New HIV diagnoses in the East Midlands in the years 2000 and 2009 were 100 and 314 respectively, while first AIDS diagnoses were 32 and 27 respectively.
Health Protection Agency: East Midlands. New HIV Diagnoses to end of December 2010

11. New HIV diagnoses in the East Midlands 1994 - 2010
2339
1729
From the years the total number of new HIV diagnoses in the region was 4,068 and from those 2,339 were men and 1729 were women.

12. Origin of HIV infected individuals in East Midlands

13. HIV testing
If HIV treatment improves the outcome of treatment for lymphoma should untested patients be tested for HIV?
Lymphoma can be the first presentation of HIV infection

14. In comparison with TB Now 10 yrs ago ‘Universal offer of test’
‘Selective’
Threshold for HIV testing
Risk factors
Clinical features
Epidemiology
PCP
Tuberculosis 14

15. National Guidelines (1)
UK National Guidelines for HIV Testing 2008
British HIV Association
British Association of Sexual Health and HIV
British Infection Society
Majority of the physicians who created the guidelines were HIV specialists.

16. UK NATIONAL GUIDELINES FOR HIV TESTING 2008
HIV test should be considered in all hospital general medical admissions and in all new registrants in general practice if the prevalence of HIV is > 2.0 in 1000 population.
HIV testing should be recommended in all those with clinical indicator diseases for adult HIV infection
The UK National Guidelines for HIV testing divide the clinical indicator diseases for adult HIV infection in two major categories:
-AIDS-defining conditions
-Other conditions where HIV testing should be offered

20. National Guidelines (2)
NICE Public Health Guidance 33 and 34 (March 2011)
Endorses 2008 guideline
‘Secondary care should offer and recommend HIV testing to all patients admitted to hospital … who… have symptoms that may indicate HIV’ (as per 2008 clinical indicator diseases)
Therefore implies a ‘universal offer’ of an HIV test to all patients with lymphoma

21. PATIENTS & METHODS 96 patients with newly diagnosed lymphomas
Data collected from the multi disciplinary lymphoma meeting (MDT) reports for the time January – June 2010.
Further data about the HIV testing and the results were collected from NotIS.
The diagnoses of the lymphomas were collected from the MDT meeting reports and confirmed by the histopathology reports.
The age, sex origin and the reason for HIV testing were confirmed from the NotIS database and the patients’ notes.

22. RESULTS
Audit sample: 96 patients with newly diagnosed lymphoma between January-June 2010.
39/96 patients had DLBCL
39/96 LGNHL
12/96 HL
5/96 T-cell
1/96 BL.
14/96 were tested for HIV.

23. Cases of lymphoma diagnosed between January-July 201039 39
From the 97 patients 39 ( %) were diagnosed with high grade B-Cell NHL, 39 with low grade B-Cell NHL, 12 with HL, 5 with T- Cell NHL and only one with Burkitt’s lymphoma. 12 5 1

24. Testing for HIV HIV TEST B-CELL LG DLBCL T-CELL BL HL TOTAL YES 5 7 22 14 NO 34 32 1 10 82 39 12 96

25. Testing for HIV
14/96 patients (14.6%) were tested for HIV and of these 6/14 (43%) were tested at the time of the initial diagnosis.
Among the HIV tested patients 7/14 (50%) had DLBCL, 5/14 (35%) LG NHL and 2/14 (15%) HL.
10/14 (72%) of those who were tested were white British and 11/14 (79%) men
1/14 was positive for HIV, but his HIV diagnosis preceded the lymphoma diagnosis

26. Cases of lymphoma tested for HIV
15%
50%
35%
-More specific from the 96 patients only 14 (14,5%) have been tested for HIV.
Out of the 14 patients which have been tested for HIV 50% (7/14) were diagnosed with DLBCL , 35% (5/14) with LGNHL and 15% (2/14) with HL.

27. HIV TESTING IN MEN AND WOMEN WITH LYMPHOMA
79%
21%

28. HIV testing in different ethnic backgrounds

29. Time of HIV testing
7/39 patients with DLBCL were tested for HIV (18%) and 4/39 were tested at the time of the initial diagnosis (10%).
2/12 patients with HL tested for HIV (17%), among them 1 was tested at the time of the initial diagnosis (8.3%) and 1 was HIV+, but his HIV diagnosis preceded the lymphoma diagnosis.
5 /39 patients with LG B cell NHL were tested for HIV (13%) and among them 1 was tested at the time of initial diagnosis (2.5%).
From the 5 patients with T-cell lymphoma nobody was tested for HIV and the only patient with BL had not been tested either. 

30. Lymphomas tested for HIV at the time of initial diagnosis

31. Lymphoma patients tested for HIV

33. DISCUSSION HIV prevalence in Nottingham city PCT is 2.35/1000.
(? how many cases have been missed?)
Guidelines suggesttest every individual who attend general practice or acute medical take, if prevalence>2/1000 population.
HIV testing is cheap and easy to perform.
Audit tested the number of patients with lymphoma who were tested for HIV. The HIV prevalence is expected to be greater in this group of patients than in the general population.

34. Options in future practice
Follow national guidelines & test every lymphoma patient
Decide to test people with risk factors (e.g. sex, origin, type of lymphoma, age)
Test on the basis of being a geographical hot spot
Decide not to follow guidelines & test individuals as per clinical judgement.

36. CONCLUSIONS
Combined chemo+HAART gives better prognosis in lymphoma patients with HIVneed for a specific decision regarding HIV testing in this group of patients.
However there is no specific policy in NCH regarding HIV testing in lymphoma patients.
Prevalence of HIV in Nottingham City is estimated at 2.35 per 1,000 population.
Prevalence of HIV in lymphoma patients in NCH is probably greater than in the general population.

37. Questions What do we do now? What should be done in the future?
This audit provides a baseline
What should be done in the future?
A decision for the Haematology Dept