1. Copyright Evans 2013 HIV and opportunistic infections Dr Cariad Evans St6 Infectious Diseases/Virology

2. Some slides and photos have been removed from this presentation due to its size If this is a problem to you, please contact vbevan@bsmt.org.uk

3. Copyright Evans 2013 Objectives Understand the natural evolution of HIV. Be aware of the multitude of opportunistic infections patients can present with. Discuss 2 cases and identify ‘alarm bells’. Look at the burden of late HIV presenters.

4. Copyright Evans 2013 Natural History of HIV infection

5. Copyright Evans 2013 Primary HIV infection

6. Copyright Evans 2013 Asymptomatic stage

7. Copyright Evans 2013 Early symptomatic stage

8. Copyright Evans 2013 Symptomatic (AIDS-defining)

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10. The multitude of opportunistic infections

11. Copyright Evans 2013 Symptomatic (AIDS-defining) CD4 < 200 cells/mm3 Often have a history of previous presentations to healthcare workers. Vigilance for ‘alarm bells’ is imperative.

12. Copyright Evans 2013 Case 1 65 year old Caucasian married man 2/52 history of gradually worsening SOB Deteriorating on Augmentin and Clarithromycin Day 5 transferred to ITU for non invasive ventilation

13. Copyright Evans 2013 Oral examination on ITU

14. Copyright Evans 2013 What are the OI alarm bells?

15. Copyright Evans 2013 Retrospectoscope 1.Unwell for 1 year with 2 stone weight loss and diarrhoea –4 endoscopies 2.Generalised itchy skin eruption –Skin biopsy 3.Haematological abnormalities with elevated globulins and thrombocytopaenia –Bone marrow

16. Copyright Evans 2013 Alarm bells Pneumocystis jirovecii pneumonia Oral candidiasis Cryptosporidium Haematological abnormalities Chronic skin problems

17. Copyright Evans 2013 Progress HIV test positive ARVs commenced after 2 weeks PCP Rx Gradual improvement – 4/52 on ITU – 3/12 in hospital 2 ½ years on: – Weight regained – Bowels and skin normal – low CD4 count, despite HIV viral load <40

18. Copyright Evans 2013 Case study 2 33 year old Caucasian woman  A+E Confusion Agitated Known asthmatic – on inhalers Single mum; 2 kids at home – Smoker, occ alcohol, employed

19. Copyright Evans 2013 Clinical findings Looks v unwell: – Temp 36.8°C, – Pulse 105 reg, – Appears to have decreased power in her right arm and leg GCS falls Bloods show lymphopaenia Head CT

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21. What are the OI alarm bells?

22. Copyright Evans 2013 Retrospectoscope 2 yrs ago, ref dermatology: – severe acne + Sebaceous cyst on face DNA’d F/up 9/12 ago, ref oral surgery: – Severe oral thrush, Follow up 6/12 and 2/12 ago – ‘getting worse’ Within last 6/12: – 3 x Chest infections, attended GP 1/12 ago, ref haematology: –  Hb,  plts: DNA – letter from GP to pt

23. Copyright Evans 2013 Alarm bells Toxoplasma Likely streptococcus pneumoniae Oral candidiasis Haematological abnormalities Chronic skin problems

24. Copyright Evans 2013 Progress Broad spectrum antibiotics – Deteriorated rapidly – Not able to perform neurosurgery Lymphopaenia – HIV test: positive ITU – Died

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26. Late diagnoses Increased disability Increased mortality Most had previous contact with healthcare worker Barriers to testing

27. Copyright Evans 2013 Timing of diagnosis 50% of adults present at a late stage of HIV infection, i.e. CD4 count < 350 cells/mm 3 (within three months of diagnosis)

28. Copyright Evans 2013 CD4 Surveillance scheme

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30. HIV infection today

31. Copyright Evans 2013 Who Should be Offered HIV screening?

32. Copyright Evans 2013 Conclusions End of 2011, an estimated 96,000 people were living with HIV in the UK. Approximately one quarter (22,600, 24%) were undiagnosed and unaware. Identification and recognition of opportunistic infections is paramount in the diagnosis of HIV.