Diagnostic testing for HIV: The symptomatic patient

HIV-associated conditions HIV infection is associated with an increased risk of a range of infections some cancers HIV also has some direct effects of its own Many respiratory, oral & gut and skin conditions are HIV associated. Some HIV symptoms and conditions are systemic. Blood dyscrasias may give clues to HIV infection Work in 2s or 3s (please mix GPs and PNs) NURSES: You are not expected to know many of these things (but some are very important for you). Try to write down at least EIGHT symptoms or conditions that might be HIV-associated

HIV-associated conditions [Still in your pairs] Review your lists: Do you have at least -two cancers and two infections that are HIV associated? -Have you managed to think of at least one direct effect of the HIV virus? Do you have at least -Two skin conditions on your list? -Two oral conditions? -One lower gut condition? -One more systemic condition? -Two blood dyscrasias?

HIV Tests The UK national HIV testing guidelines recommend: ‘all patients presenting for healthcare where HIV…. enters the differential diagnosis should be routinely offered an HIV test’ With all HIV-associated conditions it is important to consider if the patient could be HIV-infected – and offer a test So which conditions are we talking about?

First chance for diagnosis: Primary HIV infection (PHI) A flu-like, or glandular fever-like, infection Typically occurs in the first 2 or 3 weeks after infection Sore throat, fever, myalgia Patients might also have rash, headache, peri- oral or peri-genital ulcers

Association between virological, immunological, & clinical events and time course of untreated HIV Reproduced with permission from e-GP: e-Learning for General Practice, RCCP

Example of primary HIV infection rash NB i) There may be NO rash ii) This rash can vary considerably in its morphology/appearance

PHI: Why it matters so much! The patient is highly infectious due to a very high viral load There is evidence that much transmission is at this stage of infection There is a better chance of partner notification, (as the infection is relatively recent) The patient’s condition can be monitored and treatment started in a timely fashion

After primary HIV infection (PHI) there is likely to be a period of 5 to 15 years when the patient has no symptoms Then other HIV-associated conditions will start to occur

Association between virological, immunological, & clinical events and time course of untreated HIV Reproduced with permission from e-GP: e-Learning for General Practice, RCCP

Oral and gut conditions Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Oral and oesophageal candida Oral hairy leukoplakia Kaposi’s sarcoma Aphthous ulcers Gingivitis Herpes simplex Chronic diarrhoea Weight loss of unknown cause NB Viral hepatitis shares risks for HIV – offer an HIV test

Oral Candida Oral candida can be either erythematous or pseudomembranous (illustrated above) in character.

Oral Hairy Leukoplakia Oral hairy leucoplakia is caused by EBV infection in an HIV positive patient with immune deficiency

Dermatology Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Severe or recalcitrant seborrhoeic dermatitis Severe or recalcitrant psoriasis Multidermatomal or recurrent herpes zoster Kaposi’s sarcoma Folliculitis – whether normal or pruritic

Cutaneous Kaposi’s sarcoma KS is a vascular tumour and is caused by human herpes virus 8 infection. KS may also affect the mouth, gastrointestinal tract, lungs and lymph nodes.

Respiratory Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Bacterial pneumonia Tuberculosis Pneumocystis pneumonia (PCP) Patients with undiagnosed HIV are at risk of PCP and this may present with progressive dyspnoea and a dry cough over 2-3 weeks: be sure not to confuse it with asthma

Apical Pulmonary Tb: CXR

Neurology Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Peripheral neuropathy Aseptic meningitis Dementia And a number of other things likely to lead to urgent referral! (eg S.O.L due to eg lymphoma or abscess).

Systemic and other Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Lymphadenopathy Sweats, PUO Weight loss Blood dyscrasias: anaemia, low platelet count, neutropaenia Lymphoma

Asymmetrical lymphadenopathy Generalised lymphadenopathy is common in HIV positive patients. Asymmetrical lymphadenopathy with or without fever may be indicative of underlying mycobacterial disease or lymphoma.

Genital conditions Call out which ones you have on your lists! The following conditions are commoner in HIV-infected people: Atypically severe STIs (warts, herpes) Cervical intraepithelial neoplasia grade 2 or above HIV infection increases the risk of cervical cancer. CIN disease is present in between 20-40% of women with HIV, and may be associated with more rapid progression to higher grade disease. Do we consider HIV in our patients referred for colposcopy? ALL patients with STIs should be offered an HIV test

Case studies One GP read ‘An HIV test I wish I had offered – the GP’s story’ One nurse read ‘An HIV test I wish I had offered – the nurse’s story’

Last chance to update your lists! How many did you miss? Link or reference to UK 2008 testing guidelines