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A Practical Guide to HIVon
World AIDS Day
Ria Daly
ST3 GU/HIV Medicine
UK Public knowledge of HIV in the UK is declining Lack of understanding about HIV and it’s relevance in
the UK For people to respect and protect themselves and
others, they need to understand the facts and reality of HIV in the UK.
International• “Universal Access and Human Rights”• Universal access to information, prevention and testing
for people at risk of infection.
What should you know about HIV?
HIV – Current UK facts and figures
HAART – Overview of HAART and it’s impact
HIV testing What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
The Law and HIV
51 ♂• Zimbabwe UK 2005
PC:
SOB 3/52 dry cough Fever Myalgia
PMH
6/12 persistent skin rash
DH
Amoxicillin
SH
Wife & 3 children
Travels with work
Initial assessment
8/11/09
T38.7°c
Clear chest RR22
Type 1 RF
Dry macular lesions
ΔΔCAP
Swine Flu
Sarcoidosis
Bloods + BC
H1N1
IVI
Co-amoxiclav
Erythromycin
Initial assessment
8/11/09
T38.7°c
Clear chest RR22
Type 1 RF
Dry macular lesions
ΔΔCAP
Swine Flu
Sarcoidosis
Bloods + BC
H1N1
IVI
Co-amoxiclav
Erythromycin
Med SpR
8/11/09
No previous HIV test
CXR
Initial InvestigationsHb 10.9
WCC 6.8
lym 0.8
neut 5.7
Plt 348
Na 142
K 4.2
Ur 7.9
Cr 89
TP 68
Alb 28
Bil 7
Alk 48
ALT 30
CRP 153
Initial assessment
8/11/09
T38.7°c
Clear chest RR22
Type 1 RF
Dry macular lesions
ΔΔCAP
Swine Flu
Sarcoidosis
Bloods + BC
H1N1
IVI
Co-amoxiclav
Erythromycin
Med SpR
8/11/09
No previous HIV test
CXR: bilateral diffuse shadowing
Δ Bilateral Severe CAP
ΔΔ Atypical
PCP
Swine flu
Consent for HIV test
D/W Micro•Co-trimoxazole•Tamiflu•PCR PCP
Initial assessment
8/11/09
T38.7°c
Clear chest RR22
Type 1 RF
Dry macular lesions
ΔΔCAP
Swine Flu
Sarcoidosis
Bloods + BC
H1N1
IVI
Co-amoxiclav
Erythromycin
Med SpR
8/11/09
No previous HIV test
CXR:bilateral diffuse shadowing
Δ Bilateral Severe CAP
ΔΔ Atypical
PCP
Swine flu
Consent for HIV test
D/W Micro•Co-trimoxazole•Tamiflu
ITU
8/11/09
Respiratory distressFi02 21% pH7.22
pC02 3.3 p02 6.7
T38.9°c
HIV test sent
CPAP
Initial assessment
8/11/09
T38.7°c
Clear chest RR22
Type 1 RF
Dry macular lesions
ΔΔCAP
Swine Flu
Sarcoidosis
Bloods + BC
H1N1
IVI
Co-amoxiclav
Erythromycin
Med SpR
8/11/09
No previous HIV test
CXR:bilateral diffuse shadowing
Δ Bilateral Severe CAP
ΔΔ Atypical
PCP
Swine flu
Consent for HIV test
D/W Micro•Co-trimoxazole•Tamiflu•PCR PCP
ITU
8/11/09
Respiratory distress
Fi02 21% pH7.22
pC02 3.3 p026.7
T38.9°c
HIV test sent
CPAP
ID
9/11/09
No Hx TB
6/12 discoid erythematous rash
Destructive nail changes
No candida/
lymphadenopathy
Chase HIV
Bronchoscopy for PCP
Urgent CD4
Prednisolone
GUM/ITU
10/11/09
HIV positive Discussed diagnosis
Expressed wish not to inform wife
Baseline bloods
GUM/ITU
10/11/09
HIV positive Discussed diagnosis
Expressed wish not to inform wife
Baseline bloods
ITU
11/11/09
Ventilated ‘if confirmed HIV positive we must inform wife despite patient’s wishes’
Bronchoscopy
GUM
10/11/09
HIV positive Discussed diagnosis
Expressed wish not to inform wife
Baseline bloods
ITU
11/11/09
Ventilated ‘if confirmed HIV positive we must inform wife despite patient’s wishes’
Bronchoscopy
ITU
12/11/09
Tracheostomy
CRP 29
Sputum IF neg
Blood PCR +ve PCP
Stop co-amoxiclav
GUM
12/11/09
Will D/W patient and family once improved sufficiently to converse
GUM
13/11
Viral screen neg
Communicate via writing
CD4 10 cell/ul
Does not wish to disclose
Wife is HCW
Agrees to disclosure if deteriorates
GUM
13/11
Viral screen neg
Communicate via writing
CD4 10 cells/ul
Does not wish to disclose
Wife is HCW
Agrees to disclosure if deteriorates
13-17/11 Improving
Ward
IV co-trimoxazole
GUM
13/11
Viral screen neg
Communicate via writing
CD4 10 cells/ul
Does not wish to disclose
Wife is HCW
Agrees to disclosure if deteriorates
13-17/11 Improving
Ward
IV co-trimoxazole
16/11 Dermatology ΔΔ Pityriasis Versicolor
Tinea corporis
Psoriatic nail disease/onychomycosis
GUM
13/11
Viral screen neg
Communicate via writing
CD4 10 cells/ul
Does not wish to disclose
Wife is HCW
Agrees to disclosure if deteriorates
13-17/11 Improving
Ward
IV co-trimoxazole
16/11 Dermatology ΔΔ Pityriasis Versicolor
Tinea corporis
Psoriatic nail disease/onychomycosis
17-23/11 VL 237864 copies/ml
Support from HA
Disclosed to wife
THT
GUM
13/11
Viral screen neg
Communicate via writing
CD4 10 cells/ul
Does not wish to disclose
Wife is HCW
Agrees to disclosure if deteriorates
13-17/11 Improving
Ward
IV co-trimoxazole
16/11 Dermatology ΔΔ Pityriasis Versicolor
Tinea corporis
Psoriatic nail disease/onychomycosis
17-23/11 VL 237864 copies/ml
Support from HA
Disclosed to wife
THT
23/11 IV-PO co-trimoxazole
Reducing dose prednisolone
See in GU clinic to commence HAART
Derm F/U Δ psoriasis
CXR
What should you know about HIV?
HIV – Current UK facts and figures
HAART – Overview of HAART and it’s impact
HIV testing What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
The Law and HIV
HPAHIV in the United Kingdom: 2009 Report
83,000 infected at the end of 2008
27% of people with HIV in the UK
are unaware of their infection
Estimated number of adults (15-59 years) living with HIV (both diagnosed and undiagnosed) in the UK: 2008
6,550
4,5505,450
1,200550450 150
13,850
24,350
2,1502,250
4,0502,850
8,950
0
5,000
10,000
15,000
20,000
25,000
MSM Heterosexualmen born in
Africa
Heterosexualwomen born in
Africa
Heterosexualmen born in
UK/elsewhere
Heterosexualwomen born inUK/elsewhere
Injecting druguser men
Injecting druguser women
Es
tim
ate
d n
um
be
r o
f p
eo
ple
liv
ing
HIV
Diagnosed
Undiagnosed
Total = 77,550 (73,000 - 83,300)Excludes 5,450 HIV infections among individuals outside the 15-59 years age range
MESH Department - Centre for Infections
Prevalence of previously undiagnosed HIV infection,
UK: 2007
Unlinked anonymous prevalence monitoring
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
London Elsewhere in UK UK overall
Pre
va
len
ce
MSM
Heterosexuals - sub-Saharan African-born
Heterosexuals - UK-born
Heterosexuals - born elsewhere
HPAHIV in the United Kingdom: 2009 Report
7,298 new diagnoses
New diagnoses among MSM remained high in 2008
New HIV and AIDS diagnoses, people living with diagnosed HIV, and deaths, among HIV-infected people,
UK: 1999-2008
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ne
w H
IV a
nd
AID
S d
iag
no
ses
an
d d
ea
ths
.
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Pe
op
le li
vin
g w
ith d
iag
no
sed
HIV
infe
ctio
n
.
Numbers with diagnosed HIV infection
HIV diagnoses
AIDS diagnoses
Deaths
MESH Department - Centre for Infections
HPAHIV in the United Kingdom: 2009 Report
Four out of every five MSM probably acquired infection in the UK.Heterosexually acquisition in the UK
740 in 2004 → 1,130 in 2008.
Preliminary data for the first six months of 2009 1 in 5 MSM &1 in 10 heterosexuals newly diagnosed with HIV were likely to have
acquired their infection within the last six months.
Number of new HIV diagnoses¹ by prevention group², UK: 1999-2008
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ne
w H
IV d
iag
no
ses
MSM
Heterosexual contact in the UK
Heterosexual contact abroad
IDU
Blood product recipients
Mother-to-child transmission
¹ Numbers will rise as further reports are received, particularly for recent years² Adjustments made for missing information relating to patient exposure
MESH Department - Centre for Infections
Why is early diagnosis important?
• Late diagnosis – Increased morbidity and mortality– Impaired response to HAART– Increased cost to health services
55% patients were diagnosed with a CD4 <350 at diagnosis in 2008, the threshold at which treatment is recommended to begin73% patients who died from HIV in 2008 had presented lateMany late presenters have been recently seen by health care professionals
500000
Natural Course of HIV Infection
1000
0
500
1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 13
Months Years after HIV infection
Relative latency
CD-4 cells
HIV RNA
200
350
CD-4 count /ml HIV RNA / ml
1000000
0
BHIVA Mortality Audit 2006
0% 10% 20% 30% 40%
NK/not stated
None of above
Treatment delayed/not provided because ineligible for NHS
Died in community without seeking care
Unable to take treatment - toxicity/intolerance
Successfully treated but suffered catastrophic event
MDR HIV, run out of options
Known HIV, not under regular care, re-presented too late
Chose not to receive treatment
Treatment ineffective due to poor adherence
Under care but had untreatable complication
Diagnosed too late for effective treatment
Death not directly related to HIV
Percentage of deaths
Early Diagnosis to Prevent Transmission
Knowledge of HIV status is assoc with reduced risk behaviour
Estimated HIV related lifetime cost per diagnosed individual
£280,000 to £360,000
Modelling has suggested that in the US 50% of new infections occur from undiagnosed individuals
Preventing 3,550 HIV infections probably acquired in the UK, and subsequently diagnosed in 2008, would have saved over £1.1 billion in future HIV-related costs
Estimated late diagnosis of HIV infection by prevention group among adults aged ≥15 years, UK: 2008
Number diagnosed = 2,760 1,630 2,950 170 7,218
20%
44%
36%
30% 32%
43%
65%61%
52%55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MSM Heterosexual men Heterosexual women Injecting drug users Overall
Pe
rce
nta
ge
dia
gn
os
ed
late
<200
<350
CD4 cell counts <200 cells/mm³ within three months of diagnosis
MESH Department - Centre for Infections
What should you know about HIV?
HIV – Current UK facts and figures
HAART – Overview of HAART and it’s impact
HIV testing What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
The Law and HIV
HAART
HAART
Highly Active Antiretroviral Therapy
1996
Suppress Viral Load & Increase CD4 counts
Combination therapy
More effective, better tolerated, simplified dosing
Decreased mortality
Late 90s
Late 90s Now
HIV-infected individuals are now living longer
0
5000
10000
15000
20000
25000
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004Year
AID
S c
ases
an
d d
eath
s
0
20000
40000
60000
80000
100000
Livin
g w
ith H
IV
AIDS Deaths Living with HIV
EUROHIV. HIV/AIDS Surveillance in Europe: End-year report 2004, No. 71 available at http://www.eurohiv.org/reports/index_reports_eng.htm (accessed April 2006)
Antiretroviral Therapy Cohort Collaboration Lancet 2008
Life expectancy in high income countries >43,000 treatment naïve patients initiated on cART
Decreased to 59.8% if CD4 <100cells/ulDecreased to 66.4% if IVDU
Life expectancy (years, adjusted)
1996-1999 2000-02 2003-2005
At age 20 36.1 41.2 49.4
At age 35 25.1 30.1 37.3
Percent surviving from 20-44 years
75.5% 79.5% 85.7%
HAART
Must be taken on time!
What should you know about HIV?
HIV – Current UK facts and figures
HAART – Overview of HAART and it’s impact
HIV testing What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
The Law and HIV
TESTING:
What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
BASHH, BHIVA & BISGuidelines for HIV Testing 2008
Aims• Facilitate increase in HIV testing in ALL health care
settings• Reduce the proportion of undiagnosed HIV• Benefit individual and public health• Encourage ‘normalisation’ of testing• Recognise the need for a newly diagnosed individual to
be immediately linked to HIV treatment and care• Maintain confidentiality within any health care setting
Opportunistic screening– 2 per 1,000 population
recommended to expand HIV testing in the local population
– 43 English Local Authorities in 2008
Testing patients with ‘clinical indicator diseases’
Who should be tested?
Opt Out’ for:All patients attending GUM or sexual health clinicsAll women attending antenatal servicesAll women attending termination of pregnancy servicesAll patients registering with drug dependency programmes reporting a history of injecting drug useAll patients diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and Lymphoma
Any other patients presenting for healthcare where HIV enters the differential diagnosis including primary HIV infection
All individuals known to be from a high prevalence country
MSM
All men and women who report sexual contact with individuals from areas of high HIV prevalence, abroad or in the UK.
Clinical Indicator Diseases
http://www.who.int/hiv/pub/en/
Do I need to counsel my patient before doing a test?
NoPre test counselling is no longer requiredHIV is a treatable conditionMost people in the UK remain fit and well on treatmentWe need to make testing easier to decrease the number of people living with undiagnosed HIV (and possibly unknowingly infecting others)All doctors, nurses and midwifes should be able to obtain informed consent
Pre test discussion
- Benefits of testing to the individual
- Window period and whether repeat testing is needed
- Details of how the result will be given
Written consent is discouraged
What to do if the result ispositive?
• Know what the next steps will be before telling the patient
• Involve your friendly GU team!
• Consider involving us pre-test in high risk patients
What should you know about HIV?
HIV – Current UK facts and figures
HAART – Overview of HAART and it’s impact
HIV testing What the guidelines say
Who should be tested?
How do I test?
Where to turn when the result is positive
The Law and HIV
The Law and HIV
Reckless transmission
9 convictions in UK
Intentional transmission
No successful prosecution
www.cps.gov.uk
What is the position on disclosure to third party?
• BHIVA briefing paper 2006
• DOH: ‘Confidentiality and Disclosure of patient information: HIV and STIs 2006
• Confidentiality v Duty of Care
• ‘you may disclose information to a known sexual contact of a patient with HIV where you have reason to think that he has not informed that person, and cannot be persuaded to do so…you should tell the patient before making the disclosure...justify your decision to disclose information’
• ‘you must not disclose information to others who have not been, and are not at risk of infection’
GMC. Serious Communicable Diseases Oct 1997
• ‘a therapeutic relationship with the patient needs to be maintained and time is often required to facilitate patient directed disclosure. This is vital to prevent the patient feeling alienated and further contact being lost, to maintain the well being of the partner and in the interests of public health’
BHIVA 2006
• ‘’failure to maintain confidentiality may give rise to legal liability’ GMC
• Breaching confidentiality:Significant risk taking behaviour
Patient must be well informed of risks of non disclosure and support offered
Index patient has no intention to inform
Sufficient time
Case law for reckless transmission, not for non-disclosure to third party.
Summary
• Increase awareness & testing
• No need for counselling
• Positive outlook for new diagnosis if early
• Compliance with HAART is paramount
• Contact us!
Thank You for Listening
Any questions?
References1. HIV in the United Kingdom: 2009 Report http://www.hpa.org.uk/2. BHIVA 2005-6 mortality audit www.bhiva.org/files/file1001379.ppt3. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV
from persons aware and unaware that they are infected with thevirus in the USA. AIDS 2006;20:1447–50.
4. Vernazza P,Hirschel B, Bernasconi E et al. An HIV-infected person onantiretroviral therapy with completely suppressed viraemia (‘effectiveART’) is not sexually infectious [French]. Bull Méd Suisses 2008;89:165–9.
5. Sanders GD, Bayoumi AM, Sundaram V et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy.New Engl J Med 2005;352:570–85.
6. British Association for Sexual Health and HIV (BASHH), British HIVAssociation (BHIVA) and British Infection Society (BIS) Guidelines forHIV Testing (Version3.8 21/5/08)
7. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies Lancet, 372: 293 -99.