1. Case 11 71 year-old white male From the UK Had lived in London Retried to South Coast town Ex-smoker EtOH - 8 units day wine/spirits Unmarried, lived alone 1

2. Case 11: June 2006 Admitted via Ophthalmology with: Probable HIV-related peripheral neuropathy Probable Pneumocystis jirovecii pneumonia CMV retinitis Sexual history: –Friend – long-term male partner –no UPAI 15 years Initial investigations: BAL: confirmed PCP CD4 7; VL 200,000 2

3. Case 11: PMH 2000Seen in Haematology for persisting lymphopenia 2000 Admitted with weight loss, watery diarrhoea 2001Admitted with cerebellar infarct 2001Seen in Neurology OPD (3 in London, 1 elsewhere) for peripheral neuropathy - unknown cause 2003Admitted with weight loss, OGD: oesophaghitis 2004 Admitted with fractured right neck of femur lymphocytes 0.5 (1.3-3.5) multiple mouth ulcers candida on mouth swab 2005“Recurrent LRTIs” throughout 2005 3

4. Case 11: June 2006 Seen in Ophthalmology OPD: vitreous detachment in left eye 2/12 history of acute onset unilateral cloudy vision OE: retinal necrosis features characteristic of CMV retinitis SOB Refractory to antibiotics from GP Admitted to hospital 4

5. Case 11: June 2006 Management: Left vitrectomy and intraocular foscarnet D/w Genitourinary Medicine team: “What is the current treatment for non-HIV-related CMV retinitis?” GUM team: “Could this be HIV-related?” Investigations: Rapid strip HIV test reactive Confirmatory 4th generation HIV test positive 5

6. Case 11: June 2006 Further management: CMV retinitis –Intraocular foscarnet –Initiated on Valgancyclovir 900mg po bd 21/7 →maintenance PCP –treated empirically with Co-trimoxazole, dose 120mg/kg bd 21/7 →prophylaxis HIV-related neuropathy –Prednisolone 60mg po od –Antiretroviral therapy initiated 6

7. Case 11: June 2006 1 day prior to planned discharge: Septicaemic shock Died despite: –vigorous fluid resuscitation –broad spectrum antibiotic cover –ITU admission –ventilatory support –maximal inotropic support Blood cultures grew Klebsiella terrigena Cause of death –1a: gram negative sepsis –1b: multi organ failure –1c: immunosupression 2°HIV 7

8. Case 11: summary 2000Haematology OPD, persisting lymphopenia 2000Gen. med. admission, watery diarrhoea, weight loss 2001General medical admission, cerebellar infarct 2001Neurology OPD, peripheral neuropathy - unknown cause 2003Gen. med. admission, weight loss - OGD: oesophagitis 2004Fracture NOF, low lymphocytes, oral candida - recorded in ED notes “lives with male partner” 2005General medical admission, LRTI – low lymphocytes 2006Ophthalmology OPD “non-HIV related CMV retinitis” 2006HIV diagnosed: PCP: CD4 7: VL 200,000 8

9. Q: At which of his healthcare interactions could HIV testing have been undertaken? 1.When he was seen with persistent lymphopenia? (2000) 2.When he was admitted with watery diarrhoea? (2000) 3.When he was admitted with cerebellar infarct? (2001) 4.When he was seen for peripheral neuropathy? (2001) 5.When he was admitted with weight loss and oesophagitis? (2003) 6.When he was admitted with a fracture and disclosed living with male partner? (2004) 7.When he was admitted with recurrent LRTI? (2005) 8.When he was seen for “non-HIV-related CMV retinitis”? (2006) 9

10. Who can test? 10

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. Who to test? 13

14. Who to test? 14

15. Who to test? 15

16. 2000Haematology OPD, persisting lymphopenia 2000Gen. med. admission, watery diarrhoea, weight loss 2001General medical admission, cerebellar infarct 2001Neurology OPD, peripheral neuropathy - unknown cause 2003Gen. med. admission, weight loss - OGD: oesophagitis 2004Fracture NOF, low lymphocytes, oral candida - recorded in ED notes “lives with male partner” 2005General medical admission, LRTI – low lymphocytes 2006Ophthalmology OPD “non-HIV related CMV retinitis” 2006HIV diagnosed: PCP: CD4 7: VL 200,000 16 8 missed opportunities – 5 in ED - to diagnose HIV before terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

17. Learning Points This patient had numerous investigations and 5 admissions over 6 years, causing him much distress and costing the NHS thousands of pounds Some patients might not disclose risk factors for HIV on routine questioning in Outpatients even if the right questions are asked 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 17

18. 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 is >1/1000 as it has been shown to be cost-effective HIV screening should become a routine test on presentation of lymphopenia, PUO, chronic diarrhoea and weight loss of otherwise unknown cause 18

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