1. Case 12 42 year-old female From South Asia In UK 8 years Living in London

2. Case 12: Feb 2008 Seen in a London ED and admitted to hospital with: Night sweats Weight loss (4kg) Intermittent shoulder pain Lesions on legs Subsequent rash on face (burning), legs, forearms and trunk (mildly itchy)

3. Case 12: inpatient 3-night hospital admission - treated with ‘antibiotics’. Discharged. Diagnosed with erythema nodosum and chicken pox on clinical grounds No investigations for TB or HIV But referred to Respiratory Medicine - ?

4. Case 12: March 2008 Seen in Respiratory OPD PUO queried TB Elispot positive Chest X-ray clear ESR and CRP elevated Abnormal liver function tests (ALP 121,ALT 198) Hepatitis B serology ‘previous infection’ LATENT TB DIAGNOSED Referred to Dermatology for rashes on face and body

5. Case 12: April 2008 Seen in Dermatology OPD Face - fixed erythema + papules/pustules – rosacea clinically Legs - indurated nodular lesions – erythema nodosum clinically Non-specific eczematous eruption on trunk, forearms Nodular indurated lesions on hands

6. Case 12: April 2008 Differential Diagnosis: Cutaneous tuberculid Lupus erythematosus Sarcoidosis Rosacea (face) HIV

7. Case 12: April 2008 Investigations: Skin biopsies –Non specific perivascular inflammation –Fungal stains negative –IMF negative –Fungal/AFB/bacterial cultures- negative Elevated IgA & IgG Autoimmune profile negative HIV antibody positive CD4 198; VL 22,738

8. Case 12: summary 2000Registered with GP Feb 2008 General medical admission March 2008 Seen in Respiratory OPD – PUO queried, previous Hep B identified, latent TB diagnosed April 2008Seen in Dermatology OPD; cryptic presentation HIV diagnosed: CD4 198: VL 22,738

9. Q: At which of her healthcare interactions could HIV testing have been performed? 1.When she first registered with her GP? 2.When she presented to the ED with weight loss and was admitted? 3.When she presented to Respirology OPD with suspected PUO, previous Hep B was identified and latent TB was diagnosed? 4.Should she have been referred to GUM to see a trained counsellor before HIV testing?

10. Who can test?

11. Who to test?

13. 13 Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

14. Who to test?

16. 2000Registered with GP Feb 2008 General medical admission, weight loss March 2008 Seen in Respiratory OPD - PUO queried, previous Hep B identified, latent TB diagnosed April 2008Seen in Dermatology OPD; cryptic presentation HIV diagnosed: CD4 198; VL 22,738 3 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 8 years earlier

17. Learning Points This patient came from a country of low HIV prevalence and was probably not believed to be at risk of HIV infection Because of this the otherwise excellent medical teams looking after her presumably did not think of HIV even though the diagnosis seems obvious with hindsight However, the suspected PUO and Hepatitis B and TB diagnoses were a red flag for possible HIV infection A perceived lack of risk should not deter you from offering a test when clinically indicated

18. 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 screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective HIV screening should be a routine test on presentation of PUO or weight loss of otherwise unknown cause HIV screening should be routine in services for patients diagnosed with Hepatitis B and TB Key messages

19. 19 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345