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2
<45 years at seroconversion
0.0
0.2
0.4
0.6
0.8
1.0
0 5 10 15 0 5 10 15
>45 years at seroconversion
Estim
ated
cum
ulat
ive m
orta
lity
Time since seroconversion (years)
All-cause mortality pre-1996 and 2004-06(sexual exposure only)
Pre-1996 (HIV infected)
2004- 2006 (HIV infected)
2004- 2006 (general uninfected)
Porter K, et al. 15th CROI 2008 Abstract 14
Fig 1 Fig 2
Estimated prevalence of HIV infection in adults*in the UK at the end of 2007
3
•Aged 15-59 inclusive - excludes those who have died during the year
Fig 3
Estimated prompt1 and late2 HIV diagnosis3 in MSM with associated short-term mortality4: UK (1998- 2007)
5
Fig 5 Fig 6
Estimated prompt1 and late2 HIV diagnosis3 in black Africans and Caribbeans with associated short-term mortality4:UK (1998-2007)
6
Fig 7 Fig 8
7
Cost of care after HIV diagnosis in Canada
Gill WJ, Krentz HB. Poster 12C1070. 11th European AIDS Meeting, Madrid, 24–27 October 2007
Mea
n c
ost
(C
$)Fig 9
Total Inpatient Outpatient ARV drugs
Cost category
0
5000
10000
15000
20000
25000
<1 year >1 year <1 year >1 year <1 year >1 year <1 year >1 year
CD4 <200CD4 >200
BHIVA Audit 2006: Scenario leading to death
8
Source: Mortality audit 2005-06, BHIVA Audit and Standards Sub-Committee 2006, www.bhiva.org
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
Top bars: reclassified during audit
Bottom bars: as initially reported
Fig 10
Missed opportunities to detectchronic HIV infection? UK
Location
(Time Period)
Definition Group % presenting to any health care
% HIV related
UK (BHIVA)
20031
CD4 < 200 2° Care N/A 17% within 12 months
Brighton
2000-20052
AIDS at diagnosis
2° Care 62% 26%
Brighton
2000-20052
AIDS at diagnosis
1° Care 80% 60%
London
(SONHIA)
2004-20063
AIDS or CD4 <200
1° Care 75% in primary care in last 2 years
N/A
9
1Sullivan et al. BMJ, 2005; 2Ottewill, BHIVA 2006; 3Burns, BHIVA 2006
Fig 11
Missed opportunities to detectprimary HIV infection?
Location % symptomatic
% seen in HC
Diagnosis made comments
US1 89% 88% 26%
(10% of total)
15% hospitalised !
US2 n/a 52% 17% most seen > 3 times
Brighton3 71% 51% 56%
(19% of total)
GP >> A&E > others
10
• Brighton study: almost all MSM with pharyngitis, fever, rash• HCWs frequently not aware of patient’s sexual orientation
• Significance of PHI in driving onward transmission• infectiousness• sexual behaviour
1Shacker, Ann Int Med 1996; 2Weintrob, Ann Int Med 2003; 3Sudarshi, BHIVA 2006
Fig 12
Informing clinicians about“Missed HIV”
33
5
11
60 4
HIVSTDID/Public HealthGeneral MedicinePrimary CareSpeciality medicine
• “Pubmed” search;
2000-2007• “late” or “missed” or
“opportunity”
“diagnosis”
“HIV” “AIDS”• 421 entries• 59 consistent with them
11
Fig 13
83% of publications about late HIV diagnosis appeared in HIV/STD/ID/public health journals
Missed opportunities?Chronic Infection:• Secondary Care
– Brighton: 62% of late diagnoses had been seen in secondary care in previous 2 years; 26% with HIV related problem1
• Primary Care– Brighton: 80% of late diagnoses had been seen in primary care
in previous 2 years; 60% with HIV related problem1
• Accident and Emergency– Brighton: 2.5% of those with symptoms consistent with primary
HIV had undiagnosed infection2
Primary HIV Infection:– 71% symptomatic; 51% seen in healthcare; 56% diagnosed –
19% of total3
– 1/680 men aged 18-50 with symptoms of PHI were seroconverting: ?not being blood-tested?2
12
1Ottewill M et al. BHIVA 2006; 2Nambiar K et al. BHIVA 20083 Sudarshi D et al. Sex Transm Infect 2008
Undiagnosed HIVand onward transmission
13
Marks et al. AIDS 2006
75
2554
0%10%
20%30%
40%50%
60%70%
80%90%
100%
Undiagnosed ordiagnosed HIV
New HIVDiagnoses
46
(70)
(30)
54
Fig 14
Effect of knowing HIV statuson sexual behaviour
• Meta-analysis of 11 analyses of sexual behaviour– 6 compared HIV+ “aware” versus HIV+ “unaware”– 5 compared pre- and post- HIV seroconversion– All looked at self-reported rates of unprotected anal or
vaginal intercourse
• UAV 53% (CI 45-60%) lower in those aware versus unaware of HIV+ status– If only considering where partner HIV-, 68% (CI 59-
76%)
14
Marks et al. JAIDS 2005
Summary
• Earlier diagnosis decreases:– morbidity– mortality– onward transmission
• Routine/opt-out testing is acceptable to patients• Good practice - not to offer a test might be
considered negligent• Pressure from specialists/CMO
15
16
Also contains
UK National Guidelines for HIV Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected] or 020 7383 6345