A Practical Guide to HIV on World AIDS Day

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A Practical Guide to HIVonWorld AIDS Day

• Ria Daly
• ST3 GU/HIV Medicine

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• UK
• Public knowledge of HIV in the UK is declining
• Lack of understanding about HIV and its
  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.

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What should you know about HIV?

• HIV Current UK facts and figures
• HAART Overview of HAART and its 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

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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

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Initial assessment 8/11/09 T38.7c Clear chest RR22 Type 1 RF Dry macular lesions ??CAP Swine Flu Sarcoidosis Bloods BC H1N1 IVI Co-amoxiclav Erythromycin





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Initial assessment 8/11/09 T38.7c Clear chest RR22 Type 1 RF Dry macular lesions ??CAP Swine Flu Sarcoidosis Bloods BC H1N1 IVI Co-amoxiclav Erythromycin
Med SpR 8/11/09 No previous HIV test CXR




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Initial Investigations
Hb 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
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Initial assessment 8/11/09 T38.7c Clear chest RR22 Type 1 RF Dry macular lesions ??CAP Swine Flu Sarcoidosis Bloods BC H1N1 IVI Co-amoxiclav Erythromycin
Med SpR 8/11/09 No previous HIV test CXR bilateral diffuse shadowing ? Bilateral Severe CAP ?? Atypical PCP Swine flu Consent for HIV test D/W Micro Co-trimoxazole Tamiflu PCR PCP



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Initial assessment 8/11/09 T38.7c Clear chest RR22 Type 1 RF Dry macular lesions ??CAP Swine Flu Sarcoidosis Bloods BC H1N1 IVI Co-amoxiclav Erythromycin
Med SpR 8/11/09 No previous HIV test CXRbilateral diffuse shadowing ? Bilateral Severe CAP ?? Atypical PCP Swine flu Consent for HIV test D/W Micro Co-trimoxazole Tamiflu
ITU 8/11/09 Respiratory distress Fi02 21 pH7.22 pC02 3.3 p02 6.7 T38.9c HIV test sent CPAP


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Initial assessment 8/11/09 T38.7c Clear chest RR22 Type 1 RF Dry macular lesions ??CAP Swine Flu Sarcoidosis Bloods BC H1N1 IVI Co-amoxiclav Erythromycin
Med SpR 8/11/09 No previous HIV test CXRbilateral diffuse shadowing ? Bilateral Severe CAP ?? 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 T38.9c 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
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GUM/ITU 10/11/09 HIV positive Discussed diagnosis Expressed wish not to inform wife Baseline bloods





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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 patients wishes Bronchoscopy




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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 patients 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
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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





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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




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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 ?? Pityriasis Versicolor Tinea corporis Psoriatic nail disease/onychomycosis



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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 ?? Pityriasis Versicolor Tinea corporis Psoriatic nail disease/onychomycosis
17-23/11 VL 237864 copies/ml Support from HA Disclosed to wife THT


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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 ?? 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 ? psoriasis
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CXR
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What should you know about HIV?

• HIV Current UK facts and figures
• HAART Overview of HAART and its 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

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HPA HIV 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

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Prevalence of previously undiagnosed HIV
infection, UK 2007
Unlinked anonymous prevalence monitoring
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HPA HIV in the United Kingdom 2009 Report

• 7,298 new diagnoses
• New diagnoses among MSM remained high in 2008

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HPA HIV 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.

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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 lt350 at
  diagnosis in 2008, the threshold at which
  treatment is recommended to begin
• 73 patients who died from HIV in 2008 had
  presented late
• Many late presenters have been recently seen by
  health care professionals

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Natural Course of HIV Infection
CD-4 count /ml
HIV
RNA / ml
1000000
Relative latency
1000
HIV RNA
CD-4 cells
500000
500
350
200
0
0
1 2 3 4 5 6 1 2 3 4 5
6 7 8 9 10 11 12 13 Months
Years after HIV infection

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BHIVA Mortality Audit 2006
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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

• 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

• Modelling has suggested that in the US 50 of new
  infections occur from undiagnosed individuals

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What should you know about HIV?

• HIV Current UK facts and figures
• HAART Overview of HAART and its 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

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HAART
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HAART

• Highly Active Antiretroviral Therapy
• 1996
• Suppress Viral Load Increase CD4 counts
• Combination therapy
• More effective, better tolerated, simplified
  dosing
• Decreased mortality

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Late 90s
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Late 90s
Now
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HIV-infected individuals are now living longer
25000
100000
20000
80000
15000
60000
AIDS cases and deaths
Living with HIV
10000
40000
5000
20000
0
0
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Year
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.h
tm (accessed April 2006)
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Antiretroviral Therapy Cohort Collaboration
Lancet 2008

• Life expectancy in high income countries
• gt43,000 treatment naïve patients initiated on
  cART
• Decreased to 59.8 if CD4 lt100cells/ul
• Decreased 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
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HAART

• Must be taken on time!

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What should you know about HIV?

• HIV Current UK facts and figures
• HAART Overview of HAART and its 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

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TESTING

• What the guidelines say
• Who should be tested?
• How do I test?
• Where to turn when the result is positive

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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

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• 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

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Who should be tested?

• Opt Out for
• All patients attending GUM or sexual health
  clinics
• All women attending antenatal services
• All women attending termination of pregnancy
  services
• All patients registering with drug dependency
  programmes reporting a history of injecting drug
  use
• All patients diagnosed with Tuberculosis,
  Hepatitis B, Hepatitis C and Lymphoma

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• 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.

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Clinical Indicator Diseases
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http//www.who.int/hiv/pub/en/
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Do I need to counsel my patient before doing a
test?

• No
• Pre test counselling is no longer required
• HIV is a treatable condition
• Most people in the UK remain fit and well on
  treatment
• We 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

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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

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What to do if the result is positive?

• 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

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What should you know about HIV?

• HIV Current UK facts and figures
• HAART Overview of HAART and its 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

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The Law and HIV

• Reckless transmission
• 9 convictions in UK

• Intentional transmission
• No successful prosecution
• www.cps.gov.uk

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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

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• 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 soyou
  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

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• 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

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• 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.

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Summary

• Increase awareness testing
• No need for counselling
• Positive outlook for new diagnosis if early
• Compliance with HAART is paramount
• Contact us!

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• Thank You for Listening
• Any questions?

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References

• HIV in the United Kingdom 2009 Report
  http//www.hpa.org.uk/
• BHIVA 2005-6 mortality audit www.bhiva.org/files/f
  ile1001379.ppt
• Marks G, Crepaz N, Janssen RS. Estimating sexual
  transmission of HIV from persons aware and
  unaware that they are infected with the
• virus in the USA. AIDS 200620144750.
• 4. Vernazza P,Hirschel B, Bernasconi E et al. An
  HIV-infected person on
• antiretroviral therapy with completely
  suppressed viraemia (effective
• ART) is not sexually infectious French. Bull
  Méd Suisses 2008891659.
• 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 200535257085.
• 6. British Association for Sexual Health and HIV
  (BASHH), British HIV
• Association (BHIVA) and British Infection
  Society (BIS) Guidelines for
• HIV 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.