Case 2

• 50 year-old man from Hong Kong

• In UK for 35 years

• Living in South Coast town

• Married 25 years

1

Case 2: PMH

Mid June 2006 GP referral to Gastroenterology with history of weight loss and anaemia Hb 8.5

End June 2006 OGD: antral gastritis with multiple erosions: biopsies taken: benign

Mid July 2006 colonoscopy: normal to caecum with no mucosa abnormalities

Planned OPD 6 weeks (no record)

2

Case 2: Autumn 2007

GP referral to Hepatology with abnormal LFTs • ALP 196, Bilirubin 21, ALT 100 Hb 11.9, low

white cell count

Seen by Hepatology• No history of liver disease; no jaundice; no

medications; no drug use; no herbal medications or Chinese tea; no alcohol.

• In view of ethnicity? Chronic Hepatitis B

3

Case 2: Autumn 2007

• HBsAg positive, HBeAg positive, HCV negative

• USS normal; declined liver biopsy • Liver screen otherwise normal (no HIV test)

• Started lamivudine and adefovir

4

Case 2: June/July 2008

GP referral to Oral Surgery: seen end June 2008

• Large healing ulcer left palate • Biopsied beginning July 2008• Seen with result mid July 2008• Diffuse large B-cell lymphoma• Referred to Oncology

5

Case 2: PMH (cont.)

From GP letter of June 2008:

• Seen for severe psoriasis in Sept 2003

• Seen for oral candida in May 2006

6

Case 2: August 2008

Seen by Oncology beginning August 2008

• HIV test – positive

• B-cell lymphoma:– localised disease– No “B” symptoms

• R-CHOP commenced as inpatient

7

Case 2: August 2008

• HIV: CD4 count 0 (0%) VL 167,505

Resistance test sent

Antiretrovirals started mid August 2008

Truvada; Etravirine; Raltegravir; T-20

2 week CD4 1 VL 9404

Resistance test shows drug resistance (M184V)

8

Case 2: summary

Sept 2003 psoriasis

May 2006 oral candida

June 2006 anaemia, weight loss

OGD: gastritis, colonoscopy: NAD

Nov 2007 abnormal LFTs; low WCC

chronic hepatitis B

July 2008 ulcer on palate: large B-cell lymphoma

Aug 2008 HIV diagnosed: CD4 0: VL 167,505

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Q: At which of his healthcare interactions could HIV testing have been performed?

1. When he saw his GP for psoriasis?

2. When he saw his GP for oral candida?

3. When he was seen in Gastroenterology for anaemia/weight loss?

4. When he was found by Hepatology to have low WCC/hepatitis B?

5. When he was seen in ENT for oral surgery?

6. Should he have been referred to GUM to see a trained counsellor before HIV testing?

10

Who can test?

11

Who to test?

12

Who to test?

13

Who to test?

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Who to test?

Sept 2003 psoriasis

May 2006 oral candida

June 2006 anaemia, weight loss

OGD: gastritis, colonoscopy: NAD

Nov 2007 abnormal LFTs; low WCC

chronic hepatitis B

July 2008 ulcer on palate: large B-cell lymphoma

Aug 2008 HIV diagnosed: CD4 0: VL 167,505

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5 missed opportunities!If current guidelines used, HIV could have been diagnosed up to 5 years earlier

Learning Points

• Because of his nadir CD4 of 0 he has an increased risk of potential problems despite control of his HIV now

• He did not disclose any risk factors when his initial medical history was taken

• 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

• Test for HIV before treating for hepatitis B as resistance to lamivudine can compromise future HIV treatment options

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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 routine HIV testing for patients diagnosed with hepatitis B and lymphoma

• HIV screening should become a routine test performed whenever there is a clinical indicator such as oral candida or weight loss

• Some patients may not disclose that they have put themselves at risk of HIV infection in the past

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Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

enquiries@medfash.bma.org.uk or 020 7383 6345