1. Case 8 38 year-old man from Sub-Saharan Africa Came to UK in 2001 Living in London First wife died 10 years ago of TB Remarried for 7 years, wife currently pregnant (antenatal HIV screening negative) 1

2. Case 8: PMH 2001Registered with GP 2004Hypertensive – treatment started Recurrent knee problems 2006Arthroscopy - conservative treatment recommended 2007PUO/suspected malaria Admitted for 48 hours and found to be anaemic (Hb 9.8) Treated with anti-malarials and antibiotics. HIV test not offered 2008>10 kg weight loss noted Said he had been trying to lose weight as previously overweight 2

3. Case 8: late July 2009 Presented to GP with: Flu-like illness (presumed H1N1 treated with Tamiflu) Herpes Zoster left trunk Offered HIV test HIV positive CD4 189 Viral load 90,000 Hb 8.7 3

4. Case 8: summary 2001Registered with GP From 2004Seeing GP for hypertension 2006Pre-op screening - arthroscopy 2007Admitted for PUO/suspected malaria and anaemia 2008GP notes >10 kg weight loss since Nov 2007 2009Seen by GP for Herpes zoster HIV diagnosed: CD4 189, VL 90,000 4

5. Q: At which of his healthcare interactions could HIV testing have been performed? 1.When he first registered with his GP? 2.When he saw GP for hypertension? 3.When he was admitted by the orthopaedic team for arthroscopy? 4.When he was admitted for PUO/malaria and noted to have anaemia? 5.When his GP noted his >10kg weight loss? 6.Should he have been referred to GUM to see a trained counsellor before HIV testing? 5

6. Who can test? 6

7. Who to test? 7

8. 8

9. 9

10. 10 HIV prevalence (%) in adults (15–49) in Africa, 2007 2008 Report on the global AIDS epidemic

11. Who to test? 11

12. 12 Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

13. 2001Registered with GP From 2004Seeing GP for hypertension 2006Pre-op screening - arthroscopy 2007Admitted for PUO/suspected malaria and anaemia 2008GP notes >10 kg weight loss since Nov 2007 2009Seen by GP for Herpes zoster HIV diagnosed: CD4 189, VL 90,000 13 At least 5 missed opportunities! If current guidelines used, HIV diagnosed 8 years earlier

14. Learning Points This patient came from an area of high HIV prevalence, but was not offered an HIV test in numerous contacts with healthcare services His wife had tested HIV-negative, but this is no guarantee of his being HIV-negative A perceived lack of risk should not deter you from offering a test when clinically indicated HIV screening should be a routine test on presentation of a blood dyscrasia, PUO or weight loss of otherwise unknown cause 14

15. 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 UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence >1/1000 as it has been shown to be cost-effective 15

16. 16 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345