Download HIV in Primary Care

Clinical HIV infection
Gail Crowe
Princess Alexandra Hospital
2003/04
1
Objectives
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Epidemiology
Natural history
Seroconversion
Testing for HIV
HIV indicator diseases
Treatment
2003/04
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Global Estimates for Adults and
Children 2007
2003/04
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Estimated Number of People
Living With HIV Globally 19902007
2003/04
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Estimated Number of Adult and Child
Deaths Due to HIV Globally 19902007
2003/04
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Adults and Children Living With
HIV Globally 2007
2003/04
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Estimated number of adults (15-59 years) living with HIV
(both diagnosed and undiagnosed) in the UK: 2008
Estimated number of people living HIV
25,000
24,350
Diagnosed
Undiagnosed
Total = 77,550 (73,000 - 83,300)
Excludes 5,450 HIV infections among
individuals outside the 15-59 years age range
20,000
15,000
13,850
10,000
8,950
6,550
5,450
5,000
4,050
2,850
4,550
2,250
2,150
1,200
450
550 150
0
MSM
2003/04
Heterosexual
men born in
Africa
Heterosexual Heterosexual Heterosexual
women born in men born in women born in
Africa
UK/elsewhere UK/elsewhere
Injecting drug
user men
Injecting drug
user women
MESH Department - Centre for Infections
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Diagnosed HIV-infected persons accessing care by
prevention group1 and ethnic group2, UK
20,000
White MSM
Black African heterosexuals
White heterosexuals
Non-white MSM
Numbers accessing care
15,000
All other heterosexuals
IDU
Other
10,000
5,000
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
1Numbers
2Ethnic
accessing care exclude those where exposure category was not reported (1,552 in 2006)
group was allocated proportionally where it was not reported
2003/04
Annual
survey of HIV-infected persons accessing care
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UK number of HIV diagnoses by
year of diagnosis
9000
8000
7000
6000
5000
4000
3000
2000
1000
2003/04
07
06
08
20
20
20
05
20
04
20
03
20
02
20
00
01
20
99
20
19
98
19
97
19
96
19
95
93
94
19
19
19
92
19
91
19
90
19
89
19
87
88
19
19
19
86
0
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Number of new HIV diagnoses¹ by prevention group²,
UK: 1999-2008
4,500
4,000
New HIV diagnoses
3,500
MSM
Heterosexual contact in the UK
Heterosexual contact abroad
IDU
Blood product recipients
Mother-to-child transmission
3,000
2,500
2,000
1,500
1,000
500
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
¹ Numbers will rise as further reports are received, particularly for recent years
² Adjustments made for missing information relating to patient exposure
MESH Department - Centre for Infections
2003/04
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Estimated late diagnosis of HIV infection by prevention
group among adults aged ≥ 15 years, UK: 2008
100%
CD4 cell counts <200 cells/mm³ within three months of diagnosis
90%
<200
Percentage diagnosed late
80%
<350
70%
65%
61%
60%
55%
52%
50%
43%
44%
40%
36%
30%
32%
30%
20%
20%
10%
0%
MSM
Number diagnosed = 2,760
Heterosexual men
1,630
Heterosexual women Injecting drug users
2,950
170
Overall
7,218
MESH Department - Centre for Infections
2003/04
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HIV in the UK: 2008
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83,000 living with HIV
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40% of HIV probably acquired in UK
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2/3 of these are in gay men
31% of new diagnoses “late”
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22,400 unaware of diagnosis
ie CD4 <200
56,556 HIV+ people accessed care
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2003/04
70% on ARVs
8% >55 yrs old
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HIV Attendances at PAH
160
140
120
100
3-D Column 1
80
60
40
20
0
1997
2003/04
1999
2001
2003
2005
2007
2009
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HIV Attendances by Risk Factor
100
90
80
70
60
50
40
30
20
10
0
Gay men
Black African
IVDU
White Heterosexual
Other
1997 1999 2001 2003 2005 2007 2009
2003/04
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Attendances by CDC Grade
120
100
80
A
B
C
60
40
20
0
1997
2003/04
1999
2001
2003
2005
2007
2009
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Natural history
Over course of infection:
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CD4 count declines & HIV viral load increases
Increasing risk of developing infections and
tumours
The severity of these illnesses is greater the
lower the CD4 count
Most AIDS diagnoses occur at CD4 count <200
2003/04
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Natural history
Acute infection – seroconversion
Asymptomatic
HIV related illnesses
AIDS defining illness
Death
2003/04
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Primary HIV / seroconversion
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2003/04
Approximately 30 - 60% of patients have a
seroconversion illness.
Abrupt onset 2 – 4 weeks post exposure,
self limiting 1 – 2 weeks
Symptoms generally non-specific and
differential diagnosis includes range of
common conditions
Serological tests for HIV antibodies may be
negative or show indeterminate response
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Symptoms include:
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2003/04
Flu-like illness
Fever
Malaise and lethargy
Pharyngitis
Lymphadenopathy
Toxic exanthema
Occasionally HIV / AIDS defining illness due to
profound damage to immune system (often
temporary) e.g. oro-pharyngeal candida, zoster,
PCP
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Natural history
Acute infection – seroconversion
Asymptomatic
HIV related illnesses
AIDS defining illness
Death
2003/04
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HIV associated conditions
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Most of these conditions are common in the
general population.
Think of HIV if presentation is:
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atypical
recurrent problem
severe
Suspicion may be increased if the individual is
at possible risk of HIV infection
2003/04
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Healing herpes zoster
Picture from St George’s Hospital for educational use only
2003/04
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Oral Candida
2003/04
Picture from St George’s Hospital for
educational use only
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Severe oral hairy leukoplakia
Picture from St George’s Hospital for educational use only
2003/04
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Symptoms and parameters over time
Opportunistic
Infections
Symptomatic HIV Infection
0
2003/04
HIV RNA
HIV ab
CD4
Time
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Treatment for HIV
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Monotherapy
Dual therapy
Triple / quadruple therapy
2003/04
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Treatment for HIV (2)
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Nucleoside / nucleotide reverse
transcriptase inhibitors (Nucs)
Non nucleoside reverse transcriptase
inhibitors (NNRTI)
Protease inhibitors (PI)
Fusion inhibitors
Integrase inhibitors
CCR5 inhibitors
2003/04
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Treatment for HIV (3)
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Nucs: AZT, 3TC, , Abacavir, DDI, D4T, FTC,
Tenofovir
NNRTIs: Efavirenz, Nevirapine, Etravirine
PIs: Lopinavir, Atazanavir, Darunavir, Amprenavir,
Saquinavir, Indinavir, Ritonavir
Fusion Inhibitors: T20
Integrase Inhibitors: Raltegravir
CCR5 Inhibitors: Maraviroc
2003/04
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Side Effects of Treatment
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Nausea and vomiting, diarrhoea
Anaemia / pancytopaenia / abn LFTs
Insomnia
Rash
Lipodystrophy
Pancreatitis, peripheral neuropathy, lactic
acidosis, renal stones
2003/04
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Monitoring Treatment
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See 3 monthly
Viral load
CD4 count
Resistance tests
Therapeutic drug monitoring
2003/04
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BHIVA Guidelines
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Launched September 2008
Suggest HIV testing should be offered and
recommended in
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2003/04
Gay men
Intravenous drug users
People from high prevalence areas (sub
Saharan Africa)
Sexual partners of the above
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Risk Assessment
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Gay men – London
Gay men – outside
London
IVDU – London
IVDU – not London
Sub-Saharan Africa
2003/04
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19.1%
4.3%
3.5%(M) 5.0%(F)
0.77%(M) 0.34%(F)
5.8%(M) 8.9% (F)
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BHIVA Guidelines
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Also suggest universal testing in
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2003/04
GUM clinics
Antenatal services
TOP services
Drug dependency units
TB units
Patients with Hepatitis B
Patients with Hepatitis C
Patients with lymphoma
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BHIVA Guidelines
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Also suggest universal testing in
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2003/04
GUM clinics
Antenatal services
TOP services
Drug dependency units
TB units
Patients with Hepatitis B
Patients with Hepatitis C
Patients with lymphoma
✔
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✘
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✘
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BHIVA Guidelines
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Suggest that where an HIV indicator
disease is present, then testing should be
offered
2003/04
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Clinical Indicator Disease for
HIV
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TB
PCP
Toxo
Cerebral lymphoma
Crypto meningitis
PML
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2003/04
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Bacterial pneumonia
Aspergillosis
Aseptic meningitis
Encephalitis
SOL
Cerebral abscess
Guillain Barre
Dementia
Peripheral
neuropathy
Transverse myelitis
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Clinical Indicator Disease for
HIV
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KS
Cryptospoidiosis
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2003/04
Seb dermatitis
Severe psoriasis
Severe shingles
Oral candida
OHL
Persistent diarrhoea
Shigella, Campylobacter,
Salmonella
Unexplained wt loss
Hep B, Hep C
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Kaposi’s sarcoma
Picture from St George’s Hospital for educational use only
2003/04
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Clinical Indicator Disease for
HIV
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KS
Cryptospoidiosis
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2003/04
Seb dermatitis
Severe psoriasis
Severe shingles
Oral candida
OHL
Persistent diarrhoea
Shigella, Campylobacter,
Salmonella
Unexplained wt loss
Hep B, Hep C
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Clinical Indicator Disease for
HIV
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NHL
Cervical cancer
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2003/04
Hodgkins lymphoma
Lung ca
Anal cancer / AIN
Head and neck
cancers
Seminoma
Castlemans disease
VIN
CIN 2 or above
Thrombocytopenia,
neutropenia,
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Clinical Indicator Disease for
HIV
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CMV retinitis
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2003/04
Infective retinal
disease or
unexplained
retinopathy
Unexplained
lyphadenopathy
Chronic parotitis
“Glandular fever”
PUO
Any STI
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BHIVA Guidelines on HIV
Testing
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Suggest that, where prevalence of HIV
exceeds 2/1000 consideration should be
given to testing
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2003/04
all medical admissions
all patients registering with a GP
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HIV Prevalence By PCT
PCT
Number
accessing
HIV care
Population in HIV
1000s
prevalence
per 1000
Lambeth
2,339
196.2
11.9
Tower
Hamlets
836
152
5.5
Southend
259
93.8
2.76
Harlow
101
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2.1
2003/04
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HIV – pre test discussion
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Informed consent
Advantages and disadvantages
Risk assessment
3 month window period
Preparing for the result
Getting the result
Health promotion
2003/04
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Raising the subject of an HIV test
Communication strategies
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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?’ .
2003/04
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Raising the subject of an HIV test
Communication strategies
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2003/04
• 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?’
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Raising the subject of an HIV test
Communication strategies
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• 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?’
• Remember to emphasise the benefits of earlier
HIV diagnosis.
2003/04
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Risk Assement
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Sexual behaviour and that of partners
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Nationality, country of exposure
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History of IVDU
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Rape/sexual assault
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Occupational exposure
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Invasive procedures in unsterile conditions
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Blood/blood products / organ recipient 1975-1985
(UK)
2003/04
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Medical benefits of early HIV diagnosis
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Treatments available (HAART) not cure, but
prevent people becoming unwell
Prophylaxis against opportunistic infections
if appropriate
Appropriate investigations if unwell
Reduce perinatal transmission
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2003/04
treatment for mother
delivery method
avoidance of breastfeeding (in UK)
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Other benefits
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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
2003/04
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Case Presentation 1
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S.J
26 yr old woman from Sierra Leone
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
Now Rx Penicillin – helped initially but fevers
returned
2003/04
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Admitted to hospital with PUO
Temp 39 C, P100, BP 85/50
LN all areas, 3 cm hepar
Rx multiple ab – no or temp effect
Reluctantly agreed to HIV test – pos
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
2003/04
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Case Presentation 2
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Mr S.S.
53 yr old salesman, recently separated from wife
since 2000
Unwell for several yrs
Admitted Addenbrookes Jan 2006 with
?EBV/?CMV and abn LFTs
Seen by GP June 2007 with fatigue / malaise
Pancytopenia
2003/04
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Discussed with Haematologist – told “no
indication to do HIV test”!
Transferred to different GP in B/S
Still pancytopenia
Now also oral Candida and wt loss
Jan 2008, sent for HIV test – pos
CD4 80
Started ARV and doing well
2003/04
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Case Presentation 3
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M.C.
36 year old Zimbabwean woman
Diagnosed March 2007
CD4 0
Spent 41 days in PAH (£6,769)
Transferred to BLT – further 9 months as inpatient (£63,720)
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Total £70,489
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Died
2003/04
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The Cost of Late Diagnosis
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2007: 249 HIV bed-days
231/249 directly related to late diagnosis
Total cost £54,072
(Cost of HIV test: £3.30)
2003/04
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Summary
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Natural history
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Benefits of knowing status
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Seroconversion
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Other indicators of HIV infection - when to think
of HIV
Treatment and monitoring
2003/04
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Where to Look for Help
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http://www.medfash.org.uk
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Has produced excellent booklet on HIV in
Primary Care available free from website
http://www.bhiva.org
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2003/04
For testing and treatment guidelines
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