1. 1 Case 13 80 year-old White UK male Lived with wife Living in urban area in England

2. 2 Admitted via GP with: Acute confusion History of recent weight loss Unwell for 10 months Reduced mobility One episode of urinary incontinence ? malignancy Case 13: May 2007

3. 3 TURP 1996 Chest infection 2000 Chest infection 2002 Fungal nail infection 2006 Glaucoma 2006 Pacemaker fitted 2006 - noted to have mass in right side of neck Case 13: PMH

4. 4 OE: Obvious wasting Mass in right side of neck, (biopsy result from previous week inconclusive) Rest of exam normal Case 13: May – Sept 2007

5. 5 Investigations: Lymphocyte count 0.9 Na 124 Quantiferon negative CT inflammatory mass Case 13: May – Sept 2007

6. 6 Further investigations: Repeat biopsy-atypical AAFBs Referred to ID Started on TB meds Noted to have oral candida Case 13: May – Sept 2007

7. 7 On questioning: Disclosed sexual contact in Thailand in 1990 - male and female partners HIV test positive CD4 70 Case 13: May – Sept 2007

8. 8 Further course of illness: Started on antiretrovirals and PCP prophylaxis CD4 210 after 3/12 treatment Remained confused - ? AIDS related dementia Unable to discharge home Discharged to nursing home Died 2008 Case 13: May – Sept 2007

9. 9 1996Admitted for surgery - TURP 2000Seen for chest infection 2002Seen for chest infection 2006Seen for fungal nail infections 2006Seen for glaucoma 2006Admitted for surgery – pacemaker - mass on right side of neck noted 2007Admitted via GP with: - 10 month history weight loss, dementia, lymphopenia high risk sexual contact in high prevalence area HIV diagnosed: oral candida, TB: CD4 70 Inpatient for 4 months Nursing home for 9 months Case 13: summary

10. 10 Q: At which of his healthcare interactions could HIV testing have been performed? 1.When he was admitted for TURP? 2.When he was seen for recurrent chest infections? 3.When he was found to have fungal nail infections? 4.When he was diagnosed with glaucoma? 5.When he was admitted to have a pacemaker fitted? 6.When he was admitted with a 10-month history of unexplained weight loss and found to have dementia and lymphopenia? 7.Should he have been referred to GUM to see a trained counsellor before HIV testing?

11. 11 Who can test?

12. 12 Who to test?

13. 13 Who to test? 13

14. 14 Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

15. 15 Source: UNAIDS Global Report 2008, www.unaids.org HIV prevalence (%) in adults (15–49) in Asia, 2007 2008 Report on the global AIDS epidemic Who to test?

16. 16 Who to test?

17. 17 Who to test?

18. 18 At least 5 missed opportunities! If current guidelines used, HIV could have been diagnosed 7 years earlier 1996Admitted for surgery - TURP 2000Seen for chest infection 2002Seen for chest infection 2006Seen for fungal nail infections 2006Seen for glaucoma 2006Admitted for surgery – pacemaker - mass on right side of neck noted 2007Admitted via GP with: - 10 month history weight loss, dementia, lymphopenia high risk sexual contact in high prevalence area HIV diagnosed: oral candida, TB: CD4 70 Inpatient for 4 months Nursing home for 9 months

19. 19 Learning Points This patient appeared to be at low risk of HIV and presented with problems common in older people With no behavioural risk factors in the initial medical history, the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight He had numerous investigations and a nursing home stay, causing him and his family much distress and costing the NHS thousands of pounds A perceived lack of risk should not deter you from offering a test when clinically indicated

20. 20 Key messages 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 HIV screening should be a routine test on presentation of weight loss, dementia or lymphopenia of otherwise unknown cause Some patients may not disclose that they have put themselves at risk of HIV infection in the past Opt-out and routine HIV testing overcomes barriers for staff and patients

21. 21 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345