The case for increasing

HIV testing in all medical settings

1

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 late diagnosis 1 of HIV infection by prevention group, UK: 2007

4

Fig 4

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:

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