1. HIV– epidemiology, prevention and testing
Dr Nadi Gupta
Consultant Physician in GU/HIV Medicine
Rotherham NHS Foundation Trust
2016

2. Objectives
Epidemiology
Prevention  
Testing

5. UNAIDS 90/90/90 goals set a global target of
-90% of people living with HIV being diagnosed
-90% diagnosed on ART
-90% viral suppression for those on ART by 2020

6. People living with HIV on antiretroviral therapy,
all ages, global, 2010–July 2016
Source: Global AIDS Response Progress Reporting, 2016; UNAIDS 2016 estimates.
Number (millions)
People living with HIV on antiretroviral therapy (all ages)
Global target

7. What is the picture in the UK?

8. In the UK -The number of people unaware of their HIV infection remains high
In 2015, an estimated 101,200 people with HIV in the UK
Of those, 13% were unaware of their infection (risk of onward transmission)
69% were men and 31% were women
Prevalence in the UK is 1.6 per 1,000 population approx

9. In the UK - HIV incidence among men who have sex with men (MSM) remains high
In England an estimated 2,800 MSM acquired HIV in 2015 with the vast majority acquiring the virus within the UK
Overall in 2015, 47,000 MSM were estimated to be living with HIV, of whom 12% remained undiagnosed

10. In the UK -New diagnosis rates remain high
In 2015, 6,095 people were diagnosed with HIV: this rate is higher than most other countries in western Europe
The number of people diagnosed each year in the UK has remained around 6,000 for the past five years, reflecting both testing efforts and ongoing transmission of the virus

11. In the UK - The epidemic is diverse
People living with diagnosed HIV in the UK represent a diverse group and assumptions about the characteristics of those living with HIV need to be challenged
52% of all people diagnosed in 2015 were born in the UK

13. In the UK -Timely diagnosis of HIV remains a major challenge
Fewer people are diagnosed with an AIDS-defining illness
But the numbers diagnosed late remain high
In 2015, 39% were diagnosed late
Late diagnosis = ten-fold increased risk of death in the first year of diagnosis

14. In the UK – Increase in those accessing care
In 2015, 88,769 people received HIV care in the UK, up 73% (51,449 in 2006)
Longer life expectancy due to ART
97% of the 6,095 people diagnosed in 2015 were linked to HIV clinic within 3 months
94% accessing care in 2015 were receiving ART and had an undetectable viral load and are very unlikely to pass on their infection

15. Prevalence of diagnosed HIV infection by area of residence among population aged years: UK, 2012
In areas of high prevalence of diagnosed HIV infection (≥2 diagnosed infections per 1,000 population aged years) UK national guidelines recommend expanding HIV testing among people admitted to hospital and new registrants to general practice.
In 2012, 64 of 326 (20%) Local Authorities (LAs) had a diagnosed prevalence above the two per 1,000 threshold. All but one of the 33 London LAs had a prevalence above this threshold. Outside London, the five LAs with the highest prevalence and which are above ≥2 per 1,000 were: Brighton and Hove, Salford, Manchester, Blackpool and Luton.

16. Annual new HIV and AIDS diagnoses and deaths: UK, 1999-2014

17. HIV in Sheffield
Currently, c. 800 HIV positive individuals receiving care in Sheffield
Accelerating annual numbers in MSM
Numbers of new cases of HIV has exceeded total numbers dying of AIDS in city since onset of epidemic during past 30 years

18. Objectives
Epidemiology
Prevention  
Testing

19. HIV transmission routes
Blood
Sexual
Vertical

20. HIV prevention overview
Circumcision
PEPSE
PreP
STI control
Vaccines
Microbicides
HIV diagnosis / partner notification
HAART - treatment as prevention
Behavioural
Screen blood products / needle exchange

21. Circumcision RCTs South Africa Kenya Uganda N (control) N (interven)
1582
1546
1393
1391
2522
2474
Setting
Peri-urban
urban
rural
Retention rate
92%
86%
90%
PYFU
4693
4428
6744
Risk Ratio
0.41( )
0.41 ( )
0.43 ( )

22. PEP percutaneous exposure to HIV +ve blood = 0.3%
mucocutaneous exposure = 0.09%
PEP = 28 days Combination Antiretroviral Therapy within 72 hours
PEPSE

23. Risks of sexual acquisition HIV following an exposure from a known HIV+ partner
Receptive anal intercourse %
Receptive vaginal intercourse %
Insertive vaginal intercourse %
Insertive anal intercourse 0.06%
Receptive oral sex (fellatio) %

24. PEPSE RCT evidence – none
Animal model studies – ARVs protective against vaginal or rectal infections
Uncontrolled studies
-Sao Paolo (gay men)
0.6% PEP users seroconverted
4.2% non-PEP (p<0.05)
-Rio (sexual assault)
0% PEP users
2.7% non-PEP (p<0.05)

25. Prep – highly effective preventative measure

26. Behavioural Appropriate sex education
Reduce frequency of partner change
Avoid concomitant sexual partners
Reduce high risk sexual practises
Consistent condom usage

27. Impact of HAART on HIV transmission among serodisconcordant couples
HPTN 052 study
1750 serodisconcordant couples
Malawi, Thailand, India, Zimbabwe, Brazil
Marked reduction in transmission (96%)

28. Objectives
Epidemiology
Prevention  
Testing

29. Why is HIV testing important ?

30. Benefits of knowing HIV status
Access to appropriate treatment and care
Reduction in morbidity and mortality
Reduction in mother-to-child-transmission (MTCT)
Reduction of sexual transmission
Public health
Cost-effective

31. Cost-effectiveness
Estimated direct lifetime costs of each HIV infection is £280K - £360K
Plus savings on social care, lost working days, benefits claimed, costs associated with further onward transmission

32. CMO letter 13/09/07 IMPROVING THE DETECTION AND DIAGNOSIS OF HIV IN NON-HIV SPECIALTIES INCLUDING PRIMARY CARE
Be alert to circumstances appropriate to offer and recommend an HIV test
Patients may have an unacknowledged but identifiable risk, or have symptoms or signs of HIV infection
HIV testing in general practice would expedite referral directly to HIV services

33. CMO letter 13/09/07 IMPROVING THE DETECTION AND DIAGNOSIS OF HIV IN NON-HIV SPECIALTIES INCLUDING PRIMARY CARE
2 common misconceptions create barriers to uptake and need to be dispelled:
lengthy pre-test HIV counselling is not a requirement, unless a patient requests or needs this
a negative HIV test does not need to be disclosed on applications for insurance

34. STI Testing and Life Insurance BMA / ABI Guidance Dec 2002
Sexually transmitted infections
Single episodes of STI and even multiple episodes of “non-serious” STI are not relevant
Blood-borne viruses: HIV / hepatitis B / hepatitis C
Insurers should not ask whether applicant has had a test…
Doctors should not reveal whether applicant has had test…
Insurance companies may only ask whether the applicant has had a positive test result 34 34

35. Testing for HIV – targeted testing vs screening
Clinician initiated diagnostic testing triggered by clinical indicators of immuno-suppression disease /seroconversion
Screening to reduce MTCT
Screening in high risk groups
Patient initiated requests for testing

36. UK National Guidelines for HIV testing36

38. Why do doctors not test for HIV?
Underestimate the risk of HIV in their patients
Failure to recognise HIV as a modifiable prognostic indicator
Misconception that must have detailed pre-test counselling
Misunderstanding of the implications for insurance, etc
Anxieties about false positives
…but these concerns have been overcome in the antenatal setting

39. Recognised Risk factors- Identifying high risk behaviours
Sexual contact with people from high prevalence groups – MSM, IVDUs, sub-Saharan Africa/ Thailand/ Eastern Europe/ USA etc
Multiple sexual partners
Rape in high prevalence localities
Sharing needles/ gear
Iatrogenic
MTCT from HIV + mother

40. BUT…
Failure to identify increased risk factors does not equate to having no risk !!!
Patients may not admit risk factors
Patients may be unaware of their risks

41. Maintain a high index of suspicion !
Generalised lymphadenopathy
Acute generalised rash
Glandular fever/ flu-like illnesses
Think about seroconversion

42. Maintain a high index of suspicion !
Prolonged episodes of herpes simplex
Persistent frequently recurrent candidiasis
Oral candida
Indicators of immune dysfunction

43. Maintain a high index of suspicion !
Recently developed or worsening skin conditions

44. Maintain a high index of suspicion !
Odd looking mouth lesions

45. Maintain a high index of suspicion !
Unexplained weight loss or night sweats
Persistent diarrhoea
Gradually increasing shortness of breath and dry cough
Recurrent bacterial infections including pneumococcal pneumonia

46. Consider the possibility of HIV-related illness if :
Recurrent shingles or zoster in younger patients
Persistent generalised lymphadenopathy
Unexplained wt loss or diarrhoea,night sweats,PUO
Oral/oesophageal candidiasis or hairy leucoplakia
Flu-like illness, rash, meningitis in association with another STI (eg syphilis, hepatitis B)

47. Testing for HIV Relying on perceived risk factors is inadequate
Patients may be unaware of their risks or may not admit to them
Asking about risk factors in non-specialist settings may alienate patients and reduce uptake of testing
Move towards opt-out testing in patients with suggestive symptoms/ conditions

48. Who can offer testing? Any competent healthcare professional
Normalise the test
Document verbal consent
Determine how results will be given
Discuss other issues raised by patient
Written consent unnecessary
Pre-test HIV counselling is not required, unless a patient requests this 48

49. Which screening test? Venous blood sample is preferred
Antibodies in serum detectable in >99% infected people 12 weeks post-exposure
4th generation HIV tests include IgM and p24 antigen reduces window period to < 1 month
High sensitivity and specificity
Salivary Ab screening tests available 49

50. HIV POCT Point of Care tests Fingerprick blood
Lower sensitivity and specificity
False positive and negative results 50

51. Point of Care testing- Advantages
Outreach into community settings/ non-specialist clinics
Increase patient choice
Increased access to testing and case detection
Earlier diagnosis in non-healthcare seeking individuals
Reduce risk of complications
Reduce transmission

52. Home testing kits Pharmacies Internet Home-sampling vs home-testing
Professional websites
Commercial sites
Lack of regulatory control
Home-sampling vs home-testing

53. Pit falls of self testing
Incubation/window periods
Misdiagnoses
Inadequate partner notification
Re-infection
Onward transmission

54. Managing the result Negative test Positive result or result not clear
Repeat if within “window period”
Positive result or result not clear
Phone GUM or ID for advice and arrange an appointment for within 48 hours
Explain test “reactive” and needs further investigation

55. Partner notification and HIV
Discuss with all HIV infected people early after diagnosis
The length of ‘look back’ depends on individual circumstances
Encouraged the patient to inform partners or agree to provider notification
Regularly review ongoing partner notification requirements
Document discussion of safer sex practises and PEPSE
Discuss the consequences of reckless transmission

56. Criminalisation of HIV (Nov 2006)
Offences Against the Person Act 1861, section 20; “reckless transmission” of HIV
Risk (ie transmission) has to have occurred
Only those who know their status can be criminally liable

57. Confidentiality: supplementary guidance GMC 2009
Patients diagnosed with a serious communicable disease- informing sexual contacts
Allows disclosure to a known sexual partner if at risk & unaware if you cannot persuade index to do so
Must inform the patient you are going to do so- unless it endangers contact
In contact tracing don’t reveal the identity of the patient if practicable

58. Learning Points
Advantages of diagnosing HIV status far outweigh and potential disadvantages
Early diagnosis reduces mortality and morbidity
Earlier diagnosis reduces transmission
Early diagnosis is cost-effective
Encourage asymptomatic screening
Routine HIV test in patients with suggestive symptoms/ conditions eg TB, lymphoma

59. It’s better to know !

60. Any Questions?