Case 6 58 year-old man from North America Married Recently moved to London 1

Case 6: late 2005 Registered with GP - new patient check: Lipids normal Random glucose normal FBC normal - incidental finding: low platelets Referred to Haematology OPD 2

Seen in Haematology OPD (wife present) Investigations: Platelet count 65 x 10 9 /l ( x 10 9 /l) No other symptoms Patient stated: “No risk factors for HIV” HIV test not performed Bone marrow aspirate and trephine (megakaryocytes present consistent with peripheral destruction/consumption) 3 Case 6: late 2005

Diagnosis: ‘Auto-immune thrombocytopenia’ Plan: Observe GP to monitor platelet count No plan for active treatment 4

Patient re-referred by GP to Haematology Platelet count 56 x 109/l ( x 10 9 /l) Weight loss Reviewed by Gastroenterologist/Urologist OGD, Colonoscopy, Cystoscopy performed: NAD Patient stated: “No risk factors for HIV” 5 Case 6: late 2006

HIV test (after counselling): positive Patient recalls being bisexual in 1980s/1990s and since Referral to HIV team –CD4 146 (5%) –VL 94,000 –No opportunistic infection Antiretroviral therapy commenced 6 Case 6: late 2006

Case 6: summary 2005Registered with GP, referral, low platelets 2005Seen in Haematology, thrombocytopenia 2006Re-referred to Haematology, low platelets 2006Seen by Gastroenterology and Urology for weight loss 2006HIV diagnosed: CD4 146: VL 94,000 7

Q: At which of his healthcare interactions could HIV testing have been performed? 1.When he registered with his GP and was referred to Haematology? 2.When he was first seen in Haematology? 3.When he was seen by Gastroenterology and Urology for weight loss? 4.Only after being referred to GUM for counselling before HIV testing? 8

Who can test? 9

Who to test? 10

11 Who to test?

12 Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency,

Who to test? 13

2005Registered with GP, referral, low platelets 2005Seen in Haematology, thrombocytopenia 2006Re-referred to Haematology, low platelets 2006Seen by Gastroenterology and Urology for weight loss 2006HIV diagnosed: CD4 146: VL 94, missed opportunities! If current guidelines used, HIV could have been diagnosed at least 13 months earlier

15 Anaemia Thrombocytopenia Lymphoma HIV Neutropenia Haematological presentations in HIV infection

Mode of presentation in ~ 10% (Sullivan et al, 1997) Thrombocytopenia in ~ 40% of patients –Platelet count < 50 x 10 9 /l in 1 - 5% cases Isolated thrombocytopenia –does not affect overall prognosis (Holzman et al, 1987) May be managed differently from HIV negative patients 16 Thrombocytopenia in HIV+

Mechanisms underlying thrombocytopenia Reduced productionTHINK HIV! Generalised bone marrow failure Selective megakaryocyte defects Increased consumptionTHINK HIV! Immune Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenia purpura (TTP) Abnormal distribution Sequestration (splenomegaly: infection, haemophagocytosis, cirrhosis) Dilutional 17

Classification of anaemias 18 Microcytic, hypochromicNormocytic, normochromicMacrocytic MCV 95 fl MCH 27pg Fe deficiencyHaemolytic anaemiasMegaloblastic (immune, HUS, TTP, G6PD)B12 + folate ThalassaemiaAcute blood lossAlcohol Lead poisoningMixed deficiencyLiver disease Sideroblastic anaemiaParvovirus, Infection (MAI) Myelodysplasia Drugs (septrin, dapsone, GCV)Drugs (AZT) ANAEMIA OF CHRONIC DISEASE HIV infection

This man did not have an obvious risk factor when a medical history was initially taken He had put himself at risk in the past but did not share this with anyone on routine questioning in outpatients as his wife was present Because of this the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight A perceived lack of risk should not deter you from offering a test when clinically indicated 19 Learning Points

The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective UK guidelines recommend routine opt-out HIV testing for patients with thrombocytopenia HIV screening should become a routine test when investigating PUO, chronic diarrhoea or weight loss of otherwise unknown cause UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection 20 Key messages

21 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: or