1. 2003/041 Clinical HIV infection Gail Crowe Princess Alexandra Hospital

2. 2003/042 Objectives Epidemiology Epidemiology Natural history Natural history Seroconversion Seroconversion Testing for HIV Testing for HIV HIV indicator diseases HIV indicator diseases Treatment Treatment

3. 2003/043 Overview of HIV First described 1982 First described 1982 Test available from 1985 Test available from 1985 No effective treatment available until 1996 No effective treatment available until 1996 Average life expectancy: 8 to 10 years from contracting virus Average life expectancy: 8 to 10 years from contracting virus Effective treatment available since 1996 Effective treatment available since 1996 Life expectancy comparable with uninfected person…..if treatment started early enough Life expectancy comparable with uninfected person…..if treatment started early enough

4. 2003/044 Global Estimates for Adults and Children 2007

5. 2003/045 Estimated Number of People Living With HIV Globally 1990- 2007

6. 2003/046 Estimated Number of Adult and Child Deaths Due to HIV Globally 1990- 2007

7. 2003/047 Adults and Children Living With HIV Globally 2007

8. 2003/048

9. 9 Diagnosed HIV-infected persons accessing care by prevention group 1 and ethnic group 2, UK Annual survey of HIV-infected persons accessing care 1 Numbers accessing care exclude those where exposure category was not reported (1,552 in 2006) 2 Ethnic group was allocated proportionally where it was not reported

10. 2003/0410 UK number of HIV diagnoses by year of diagnosis

11. 2003/0411

12. 2003/0412

13. 2003/0413

14. 2003/0414 HIV in the UK: 2008 83,000 living with HIV 83,000 living with HIV 22,400 unaware of diagnosis 22,400 unaware of diagnosis 40% of HIV probably acquired in UK 40% of HIV probably acquired in UK 2/3 of these are in gay men 2/3 of these are in gay men 31% of new diagnoses “late” 31% of new diagnoses “late” ie CD4 <200 ie CD4 <200 56,556 HIV+ people accessed care 56,556 HIV+ people accessed care 70% on ARVs 70% on ARVs 8% >55 yrs old 8% >55 yrs old

15. 2003/0415 HIV Attendances at PAH

16. 2003/0416 HIV Attendances by Risk Factor

17. 2003/0417 Attendances by CDC Grade

18. 2003/0418 Natural history Over course of infection: CD4 count declines & HIV viral load increases CD4 count declines & HIV viral load increases Increasing risk of developing infections and tumours Increasing risk of developing infections and tumours The severity of these illnesses is greater the lower the CD4 count The severity of these illnesses is greater the lower the CD4 count Most AIDS diagnoses occur at CD4 count <200 Most AIDS diagnoses occur at CD4 count <200

19. 2003/0419 Natural history Acute infection – seroconversion Asymptomatic HIV related illnesses AIDS defining illness Death

20. 2003/0420 Primary HIV / seroconversion Approximately 30 - 60% of patients have a seroconversion illness. Approximately 30 - 60% of patients have a seroconversion illness. Abrupt onset 2 – 4 weeks post exposure, self limiting 1 – 2 weeks Abrupt onset 2 – 4 weeks post exposure, self limiting 1 – 2 weeks Symptoms generally non-specific and differential diagnosis includes range of common conditions Symptoms generally non-specific and differential diagnosis includes range of common conditions Serological tests for HIV antibodies may be negative or show indeterminate response Serological tests for HIV antibodies may be negative or show indeterminate response

21. 2003/0421 Symptoms include: Flu-like illness Flu-like illness Fever Fever Malaise and lethargy Malaise and lethargy Pharyngitis Pharyngitis Lymphadenopathy Lymphadenopathy Toxic exanthema Toxic exanthema Occasionally HIV / AIDS defining illness due to profound damage to immune system (often temporary) e.g. oro-pharyngeal candida, zoster, PCP Occasionally HIV / AIDS defining illness due to profound damage to immune system (often temporary) e.g. oro-pharyngeal candida, zoster, PCP

22. 2003/0422 Natural history Acute infection – seroconversion Asymptomatic HIV related illnesses AIDS defining illness Death

23. 2003/0423 HIV associated conditions Most of these conditions are common in the general population. Most of these conditions are common in the general population. Think of HIV if presentation is: Think of HIV if presentation is: atypical atypical recurrent problem recurrent problem severe severe Suspicion may be increased if the individual is at possible risk of HIV infection

24. 2003/0424 Healing herpes zoster Picture from St George’s Hospital for educational use only

25. 2003/0425 Oral Candida Picture from St George’s Hospital for educational use only

26. 2003/0426 Severe oral hairy leukoplakia Picture from St George’s Hospital for educational use only

27. 2003/0427 Opportunistic Infections Symptomatic HIV Infection Symptoms and parameters over time

28. 2003/0428 Treatment for HIV Monotherapy Monotherapy Dual therapy Dual therapy Triple / quadruple therapy Triple / quadruple therapy

29. 2003/0429 Treatment for HIV (2) Nucleoside / nucleotide reverse transcriptase inhibitors (Nucs) Nucleoside / nucleotide reverse transcriptase inhibitors (Nucs) Non nucleoside reverse transcriptase inhibitors (NNRTI) Non nucleoside reverse transcriptase inhibitors (NNRTI) Protease inhibitors (PI) Protease inhibitors (PI) Fusion inhibitors Fusion inhibitors Integrase inhibitors Integrase inhibitors CCR5 inhibitors CCR5 inhibitors

30. 2003/0430 Treatment for HIV (3) Nucs: AZT, 3TC,, Abacavir, DDI, D4T, FTC, Tenofovir Nucs: AZT, 3TC,, Abacavir, DDI, D4T, FTC, Tenofovir NNRTIs: Efavirenz, Nevirapine, Etravirine NNRTIs: Efavirenz, Nevirapine, Etravirine PIs: Lopinavir, Atazanavir, Darunavir, Amprenavir, Saquinavir, Indinavir, Ritonavir PIs: Lopinavir, Atazanavir, Darunavir, Amprenavir, Saquinavir, Indinavir, Ritonavir Fusion Inhibitors: T20 Fusion Inhibitors: T20 Integrase Inhibitors: Raltegravir Integrase Inhibitors: Raltegravir CCR5 Inhibitors: Maraviroc CCR5 Inhibitors: Maraviroc

31. 2003/0431 Side Effects of Treatment Nausea and vomiting, diarrhoea Nausea and vomiting, diarrhoea Anaemia / pancytopaenia / abn LFTs Anaemia / pancytopaenia / abn LFTs Insomnia Insomnia Rash Rash Lipodystrophy Lipodystrophy Pancreatitis, peripheral neuropathy, lactic acidosis, renal stones Pancreatitis, peripheral neuropathy, lactic acidosis, renal stones

32. 2003/0432 Monitoring Treatment See 3 monthly See 3 monthly Viral load Viral load CD4 count CD4 count Resistance tests Resistance tests Therapeutic drug monitoring Therapeutic drug monitoring

33. 2003/0433 BHIVA Guidelines Launched September 2008 Launched September 2008 Suggest HIV testing should be offered and recommended in Suggest HIV testing should be offered and recommended in Gay men Gay men Intravenous drug users Intravenous drug users People from high prevalence areas (sub Saharan Africa) People from high prevalence areas (sub Saharan Africa) Sexual partners of the above Sexual partners of the above

34. 2003/0434 Risk Assessment Gay men – London Gay men – London Gay men – outside London Gay men – outside London IVDU – London IVDU – London IVDU – not London IVDU – not London Sub-Saharan Africa Sub-Saharan Africa 19.1% 19.1% 4.3% 4.3% 3.5%(M) 5.0%(F) 3.5%(M) 5.0%(F) 0.77%(M) 0.34%(F) 0.77%(M) 0.34%(F) 5.8%(M) 8.9% (F) 5.8%(M) 8.9% (F)

35. 2003/0435 BHIVA Guidelines Also suggest universal testing in Also suggest universal testing in GUM clinics GUM clinics Antenatal services Antenatal services TOP services TOP services Drug dependency units Drug dependency units TB units TB units Patients with Hepatitis B Patients with Hepatitis B Patients with Hepatitis C Patients with Hepatitis C Patients with lymphoma Patients with lymphoma

36. 2003/0436 BHIVA Guidelines Also suggest universal testing in Also suggest universal testing in GUM clinics ✔ GUM clinics ✔ Antenatal services ✔ Antenatal services ✔ TOP services ✔ TOP services ✔ Drug dependency units ✔ Drug dependency units ✔ TB units ✔ TB units ✔ Patients with Hepatitis B ✘ Patients with Hepatitis B ✘ Patients with Hepatitis C ✘ Patients with Hepatitis C ✘ Patients with lymphoma ✘ Patients with lymphoma ✘

37. 2003/0437 BHIVA Guidelines Suggest that where an HIV indicator disease is present, then testing should be offered Suggest that where an HIV indicator disease is present, then testing should be offered

38. 2003/0438 Clinical Indicator Disease for HIV TB TB PCP PCP Toxo Toxo Cerebral lymphoma Cerebral lymphoma Crypto meningitis Crypto meningitis PML PML Bacterial pneumonia Bacterial pneumonia Aspergillosis Aspergillosis Aseptic meningitis Aseptic meningitis Encephalitis Encephalitis SOL SOL Cerebral abscess Cerebral abscess Guillain Barre Guillain Barre Dementia Dementia Peripheral neuropathy Peripheral neuropathy Transverse myelitis Transverse myelitis

39. 2003/0439 Clinical Indicator Disease for HIV KS KS Cryptospoidiosis Cryptospoidiosis Seb dermatitis Seb dermatitis Severe psoriasis Severe psoriasis Severe shingles Severe shingles Oral candida Oral candida OHL OHL Persistent diarrhoea Persistent diarrhoea Shigella, Campylobacter, Salmonella Shigella, Campylobacter, Salmonella Unexplained wt loss Unexplained wt loss Hep B, Hep C Hep B, Hep C

40. 2003/0440 Kaposi’s sarcoma Picture from St George’s Hospital for educational use only

41. 2003/0441 Clinical Indicator Disease for HIV KS KS Cryptospoidiosis Cryptospoidiosis Seb dermatitis Seb dermatitis Severe psoriasis Severe psoriasis Severe shingles Severe shingles Oral candida Oral candida OHL OHL Persistent diarrhoea Persistent diarrhoea Shigella, Campylobacter, Salmonella Shigella, Campylobacter, Salmonella Unexplained wt loss Unexplained wt loss Hep B, Hep C Hep B, Hep C

42. 2003/0442 Clinical Indicator Disease for HIV NHL NHL Cervical cancer Cervical cancer Hodgkins lymphoma Hodgkins lymphoma Lung ca Lung ca Anal cancer / AIN Anal cancer / AIN Head and neck cancers Head and neck cancers Seminoma Seminoma Castlemans disease Castlemans disease VIN VIN CIN 2 or above CIN 2 or above Thrombocytopenia, neutropenia, lymphopenia Thrombocytopenia, neutropenia, lymphopenia

43. 2003/0443 Clinical Indicator Disease for HIV CMV retinitis CMV retinitis Infective retinal disease or unexplained retinopathy Infective retinal disease or unexplained retinopathy Unexplained lyphadenopathy Unexplained lyphadenopathy Chronic parotitis Chronic parotitis “Glandular fever” “Glandular fever” PUO PUO Any STI Any STI

44. 2003/0444 BHIVA Guidelines on HIV Testing Suggest that, where prevalence of HIV exceeds 2/1000 consideration should be given to testing Suggest that, where prevalence of HIV exceeds 2/1000 consideration should be given to testing all medical admissions all medical admissions all patients registering with a GP all patients registering with a GP

45. 2003/0445 HIV Prevalence By PCT PCT Number accessing HIV care Population in 1000s HIV prevalence per 1000 Lambeth2,339196.211.9 Tower Hamlets 8361525.5 Southend25993.82.76 Harlow101482.1

46. 2003/0446 HIV – pre test discussion Informed consent Informed consent Advantages and disadvantages Advantages and disadvantages Risk assessment Risk assessment 3 month window period 3 month window period Preparing for the result Preparing for the result Getting the result Getting the result Health promotion Health promotion

47. 2003/0447 Raising the subject of an HIV test Communication strategies Raising the subject of HIV with a patient can be difficult. Raising the subject of HIV with a patient can be difficult. ‘The problems that you have had recently are quite common, and usually minor. However, very occasionally they can give a clue that your immune system is not working as well as it should.’ ‘I don’t know if you are at risk of HIV, but this is one condition that can affect the immune system. Could I ask you some questions to see if you could be at risk?’. ‘The problems that you have had recently are quite common, and usually minor. However, very occasionally they can give a clue that your immune system is not working as well as it should.’ ‘I don’t know if you are at risk of HIV, but this is one condition that can affect the immune system. Could I ask you some questions to see if you could be at risk?’.

48. 2003/0448 Raising the subject of an HIV test Communication strategies Raise the subject of HIV before a sexual history has been taken – perhaps in a contraception or smear consultation. ‘HIV is much more common in people from Africa. Do you know people who have been affected? Would you like to consider having a test?’ Raise the subject of HIV before a sexual history has been taken – perhaps in a contraception or smear consultation. ‘HIV is much more common in people from Africa. Do you know people who have been affected? Would you like to consider having a test?’ Raise the subject of sexual health in a new patient check. ‘We find that quite a lot of young men are at risk of having sexual health problems. Could I ask you a few questions to see if you are at risk?’ Raise the subject of sexual health in a new patient check. ‘We find that quite a lot of young men are at risk of having sexual health problems. Could I ask you a few questions to see if you are at risk?’

49. 2003/0449 Raising the subject of an HIV test Communication strategies Raise the subject of HIV once a sexual history has been taken. ‘Because two of your partners in the last year have been male, like you, it is possible that you are at higher risk of HIV. Have you ever considered having an HIV test?’ Raise the subject of HIV once a sexual history has been taken. ‘Because two of your partners in the last year have been male, like you, it is possible that you are at higher risk of HIV. Have you ever considered having an HIV test?’ Raise the subject of HIV when a history of injecting drug use has been identified. ‘Current advice is that everyone who has injected drugs in the past should be offered a test for HIV. Have you ever considered having a test?’ Raise the subject of HIV when a history of injecting drug use has been identified. ‘Current advice is that everyone who has injected drugs in the past should be offered a test for HIV. Have you ever considered having a test?’ Remember to emphasise the benefits of earlier HIV diagnosis. Remember to emphasise the benefits of earlier HIV diagnosis.

50. 2003/0450 Risk Assement Sexual behaviour and that of partners Sexual behaviour and that of partners Nationality, country of exposure Nationality, country of exposure History of IVDU History of IVDU Rape/sexual assault Rape/sexual assault Occupational exposure Occupational exposure Invasive procedures in unsterile conditions Invasive procedures in unsterile conditions Blood/blood products / organ recipient 1975-1985 (UK) Blood/blood products / organ recipient 1975-1985 (UK)

51. 2003/0451 Medical benefits of early HIV diagnosis Treatments available (HAART) not cure, but prevent people becoming unwell Treatments available (HAART) not cure, but prevent people becoming unwell Prophylaxis against opportunistic infections if appropriate Prophylaxis against opportunistic infections if appropriate Appropriate investigations if unwell Appropriate investigations if unwell Reduce perinatal transmission Reduce perinatal transmission treatment for mother treatment for mother delivery method delivery method avoidance of breastfeeding (in UK) avoidance of breastfeeding (in UK)

52. 2003/0452 Other benefits  Minimise the risk of infecting others  Partner notification  Ability to inform important life decisions  Relief of anxiety about knowing HIV status  Access to help from social services, drug services etc

53. 2003/0453 Case Presentation 1 S.J S.J 26 yr old woman from Sierra Leone 26 yr old woman from Sierra Leone Attended GP with 6/52 hist of fever, intermittent cough, cervical lymphadenopathy Attended GP with 6/52 hist of fever, intermittent cough, cervical lymphadenopathy Nine months previously had seen GP with fatigue and was found to have mild anaemia Nine months previously had seen GP with fatigue and was found to have mild anaemia Now Rx Penicillin – helped initially but fevers returned Now Rx Penicillin – helped initially but fevers returned

54. 2003/0454 Admitted to hospital with PUO Admitted to hospital with PUO Temp 39 C, P100, BP 85/50 Temp 39 C, P100, BP 85/50 LN all areas, 3 cm hepar LN all areas, 3 cm hepar Rx multiple ab – no or temp effect Rx multiple ab – no or temp effect Reluctantly agreed to HIV test – pos Reluctantly agreed to HIV test – pos Eventually diagnosed with TB on sputum culture Eventually diagnosed with TB on sputum culture Had visited GP regularly over past 9 months c/o fatigue / malaise for which only Ix had been FBC Had visited GP regularly over past 9 months c/o fatigue / malaise for which only Ix had been FBC

55. 2003/0455 Case Presentation 2 Mr S.S. Mr S.S. 53 yr old salesman, recently separated from wife since 2000 53 yr old salesman, recently separated from wife since 2000 Unwell for several yrs Unwell for several yrs Admitted Addenbrookes Jan 2006 with ?EBV/?CMV and abn LFTs Admitted Addenbrookes Jan 2006 with ?EBV/?CMV and abn LFTs Seen by GP June 2007 with fatigue / malaise Seen by GP June 2007 with fatigue / malaise Pancytopenia Pancytopenia

56. 2003/0456 Discussed with Haematologist – told “no indication to do HIV test”! Discussed with Haematologist – told “no indication to do HIV test”! Transferred to different GP in B/S Transferred to different GP in B/S Still pancytopenia Still pancytopenia Now also oral Candida and wt loss Now also oral Candida and wt loss Jan 2008, sent for HIV test – pos Jan 2008, sent for HIV test – pos CD4 80 CD4 80 Started ARV and doing well Started ARV and doing well

57. 2003/0457 Case Presentation 3 M.C. M.C. 36 year old Zimbabwean woman 36 year old Zimbabwean woman Diagnosed March 2007 Diagnosed March 2007 CD4 0 CD4 0 Spent 41 days in PAH (£6,769) Spent 41 days in PAH (£6,769) Transferred to BLT – further 9 months as in- patient (£63,720) Transferred to BLT – further 9 months as in- patient (£63,720) Total £70,489 Total £70,489 Died Died

58. 2003/0458 The Cost of Late Diagnosis 2007: 249 HIV bed-days 2007: 249 HIV bed-days 231/249 directly related to late diagnosis 231/249 directly related to late diagnosis Total cost £54,072 Total cost £54,072 (Cost of HIV test: £3.30) (Cost of HIV test: £3.30)

59. 2003/0459 Summary Natural history Natural history Benefits of knowing status Benefits of knowing status Seroconversion Seroconversion Other indicators of HIV infection - when to think of HIV Other indicators of HIV infection - when to think of HIV Treatment and monitoring Treatment and monitoring

60. 2003/0460 Where to Look for Help http://www.medfash.org.uk http://www.medfash.org.uk http://www.medfash.org.uk Has produced excellent booklet on HIV in Primary Care available free from website Has produced excellent booklet on HIV in Primary Care available free from website http://www.bhiva.org http://www.bhiva.org http://www.bhiva.org For testing and treatment guidelines For testing and treatment guidelines