Download Late Diagnosis of HIV in Northern Ireland

Late Diagnosis of HIV in Northern
Ireland
Walker E, Todd SEJ, Rafferty P, Donnelly CM,
Emerson CR, Dinsmore WW, Quah SP, McCarty EJ
Department of Genito-Urinary Medicine, Belfast HSC
Trust, Belfast, UK.
Background
• Over 800 patients in NI with HIV
• Around 100-120 new registrations/year (newly
diagnosed/transfer of care)
• Late diagnosis of HIV remains a problem
• 10-fold increased risk of death in year following
diagnosis
• Deaths as diagnosed too late – treatment ineffective
• Near-normal life expectancy if diagnosed promptly
• Early diagnosis results in reduced onward transmission
• Large numbers unaware of diagnosis
BHIVA Guidelines (2008)
• Facilitate increase in testing across all
healthcare settings
• Aim to benefit both individual and public
health
• Encourage ‘normalisation’ of testing
• New diagnoses linked to specialist care
• Awareness of clinical indicator diseases, as
well as opportunistic screening based on
prevalence data
BHIVA National Audit (2010)
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Retrospective audit – 1112 patients
Newly diagnosed patients
52.2% had late diagnosis
62.6% diagnosed in traditional settings
33% non-traditional
Quarter of patients had missed opportunity
for earlier diagnosis
HIV in UK: 2014 Report (PHE)
• 42% diagnosed late in 2013 (57% in 2004)
• 24% CD4 <200
• Late diagnoses highest among heterosexual
men/women
• Smallest proportion among MSM
• Number of MSM diagnosed late remained stable
• More frequent testing among MSM
• Over 50 more likely to have late diagnosis (58% vs
39%)
Who should test?
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Universal testing:
GUM or sexual health clinics
Antenatal services
Termination of pregnancy services
Drug dependency programmes
Healthcare services for pts with TB, hep B and C and
lymphoma
• Consider in (where HIV prevalence > 2/1000):
• All men/women registering at GP
• All general medical admissions
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Routinely offered/recommended:
All patients where HIV enters the differential diagnosis
All patients diagnosed with an STI
All sexual partners of men and women known to be HIV positive
All men who have disclosed sexual contact with other men
All female sexual contacts of men who have sex with men
All patients reporting a history of injecting drug use
All men and women known to be from a country of high HIV prevalence (>1%)
All men and women who report sexual contact abroad or in the UK with
individuals from countries of high HIV prevalence
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Also routinely performed in:
blood donors
dialysis patients
organ transplant donors and recipients.
Clinical Indicator Diseases
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AIDS-defining conditions
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Other conditions where HIV testing should
be offered
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Respiratory
TB
PCP
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Bacterial pneumonia
Aspergillosis
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Neurology
Cerebral toxoplasmosis
Primary cerebral lymphoma
Cryptococcal meningitis
Progressive multifocal leucoencephalopathy
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Aseptic meningitis/encephalitis
Cerebral abscess
Space occupying lesion of unknown cause
Guillain–Barré syndrome
Transverse myelitis
Peripheral neuropathy
Dementia
Leucoencephalopathy
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AIDS-defining conditions
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Other conditions where HIV testing
should be offered
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Dermatology
Kaposi’s sarcoma
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Severe/recalcitrant seborrhoeic
dermatitis
Severe/recalcitrant psoriasis
Multidermatomal or recurrent herpes
zoster
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Gastroenterology
Persistent cryptosporidiosis
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Oral candidiasis
Oral hairy leukoplakia
Chronic diarrhoea of unknown cause
Weight loss of unknown cause
Salmonella, shigella or campylobacter
Hepatitis B infection
Hepatitis C infection
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AIDS-defining conditions
Oncology
Non-Hodgkin’s lymphoma
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Gynaecology
Cervical cancer
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Haematology
Other conditions where HIV testing
should be offered
Anal cancer or anal intraepithelial
dysplasia
Lung cancer
Seminoma
Head and neck cancer
Hodgkin’s lymphoma
Castleman’s disease
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Vaginal intraepithelial neoplasia
Cervical intraepithelial neoplasia
Grade 2 or above
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Any unexplained blood dyscrasia
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AIDS-defining conditions
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Other conditions where HIV testing should
be offered
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Ophthalmology
CMV retinitis
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Infective retinal diseases including HSV and
toxoplasma
Any unexplained retinopathy
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Lymphadenopathy of unknown cause
Chronic parotitis
Lymphoepithelial parotid cysts
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Mononucleosis-like syndrome (primary HIV)
PUO
Any lymphadenopathy of unknown cause
Any STI
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Other
Our Audit
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Retrospective chart analysis July 2013 – June 2014
76 total new diagnoses
45 late diagnoses (CD4 < 0.35 x 109/L)
31 severe immunocompromise (CD4 < 0.20 x 109/L)
34 men, 11 women
Age range 21 years to 65 years; mean age 44
4 patients attended GUM in past (9%)
11 patients had previous HIV test (24%)
20 % diagnosed by GUM
Remainder diagnosed via a range of specialties
Ethnicity
Ethnicity
White, NI
Black African
White other
Asian
Mode of acquisition
Mode of acquisition
Unknown
IVDU
Mode of acquisition
Heterosexual
MSM
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10
15
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25
Diagnosis by Specialty
Specialty
General Medicine
GUM
GP
Opthalmology
Respiratory
Occ Health
HDU/ICU
Antenatal
Rheumatology
Haem
Other
Previous Investigations
• 25/45 (57%) attended a number of specialties
for Ix prior to HIV diagnosis
• Wide range of tests carried out
Investigations
Test
ANA/ANCA
Coeliac Screen
CXR
H. Pylori
CT CAP
TFT
Colonoscopy
Monospot
CMV
OGD
CT sinus
BM biopsy
Clinical Indicator Disease
• 38/45 (84%) had one or more indicator
diseases
• 20/45 (44%) had one or more AIDS defining
illness
• 14/45 (31%) had PCP
• 20/45 (44%) had unexplained blood dyscrasia
AIDS defining Conditions
Condition
CMV Retinitis
NHL
Kaposi Sarcoma
Condition
Cryptococcal Meningitis
TB
PCP
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5
10
15
Other Conditions
Condition
Blood Dyscrasias
Weight loss
Syphilis
Chronic Diarrhoea
Oral candida
PUO
Hep B
Hep C
Seborrhoeic Dermatitis
Severe psoriasis
Retinopathy
Oral hairy leukoplakia
Outcomes
• 20/45 (44%) were inpatients when diagnosis
was made
• Average inpatient stay 19 days
• 5 patients (11%) had ICU/HDU admission
• 3/45 (7%) of patients died
• 41/45 (91%) commenced ARV
Conclusions
• Late diagnosis of HIV an increasing problem – 59% of
new diagnoses in NI (compared to 42% in UK)
• 41% diagnosed very late (24% in UK)
• Results in increased burden of disease with lengthy
inpatient stays
• High proportion of patients diagnosed in non-GUM
settings – increased provision of testing
• Majority of patients had one or more clinical indicator
diseases
• Opportunities for earlier diagnosis still being missed