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The case for increasing HIV testing in all medical settings. All-cause mortality pre-1996 and 2004-06 (sexual exposure only). 1.0. <45 years at seroconversion. >45 years at seroconversion. 0.8. 0.6. 0.4. 0.2. 0.0. 0. 5. 10. 15. 0. 5. 10. 15. Fig 1. Fig 2.

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Presentation Transcript
slide1

The case for increasing

HIV testing in all medical settings

slide2

All-cause mortality pre-1996 and 2004-06

(sexual exposure only)

1.0

<45 years at seroconversion

>45 years at seroconversion

0.8

0.6

0.4

0.2

0.0

0

5

10

15

0

5

10

15

Fig 1

Fig 2

Estimated cumulative mortality

Time since seroconversion (years)

Pre-1996 (HIV infected)

2004- 2006 (HIV infected)

2004- 2006 (general uninfected)

Porter K, et al. 15th CROI 2008 Abstract 14

estimated prevalence of hiv infection in adults in the uk at the end of 2007
Estimated prevalence of HIV infection in adults*in the UK at the end of 2007
  • Aged 15-59 inclusive - excludes those who have died during the year

Fig 3

slide5
Estimated prompt1 and late2 HIV diagnosis3 in MSM with associated short-term mortality4: UK (1998- 2007)

Fig 5

Fig 6

slide6
Estimated prompt1 and late2 HIV diagnosis3 in black Africans and Caribbeans with associated short-term mortality4:UK (1998-2007)

Fig 7

Fig 8

cost of care after hiv diagnosis in canada
Cost of care after HIV diagnosis in Canada

25000

20000

15000

CD4 <200

CD4 >200

10000

5000

0

<1 year

>1 year

<1 year

>1 year

<1 year

>1 year

<1 year

>1 year

Total

Inpatient

Outpatient

ARV drugs

Cost category

Fig 9

Mean cost (C$)

Gill WJ, Krentz HB. Poster 12C1070. 11th European AIDS Meeting, Madrid, 24–27 October 2007

bhiva audit 2006 scenario leading to death
BHIVA Audit 2006: Scenario leading to death

Top bars: reclassified during audit

Bottom bars: as initially reported

Fig 10

Source: Mortality audit 2005-06, BHIVA Audit and Standards Sub-Committee 2006, www.bhiva.org

missed opportunities to detect chronic hiv infection uk
Missed opportunities to detectchronic HIV infection? UK

Fig 11

1Sullivan et al. BMJ, 2005; 2Ottewill, BHIVA 2006; 3Burns, BHIVA 2006

missed opportunities to detect primary hiv infection
Missed opportunities to detectprimary HIV infection?

Fig 12

  • 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

informing clinicians about missed hiv

Fig 13

  • “Pubmed” search;

2000-2007

  • “late” or “missed” or “opportunity”

“diagnosis”

“HIV” “AIDS”

  • 421 entries
  • 59 consistent with them
Informing clinicians about“Missed HIV”

83% of publications about late HIV diagnosis appeared in HIV/STD/ID/public health journals

missed opportunities
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

1Ottewill M et al. BHIVA 2006; 2Nambiar K et al. BHIVA 2008

3 Sudarshi D et al. Sex Transm Infect 2008

undiagnosed hiv and onward transmission
Undiagnosed HIVand onward transmission

Fig 14

100%

54

25

90%

80%

54

(70)

(30)

70%

60%

50%

75

40%

30%

20%

46

10%

0%

Undiagnosed or

diagnosed HIV

New HIV

Diagnoses

Marks et al. AIDS 2006

effect of knowing hiv status on sexual behaviour
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%)

Marks et al. JAIDS 2005

summary
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
slide16

Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

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