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Case 5

Case 5. 45 year-old woman From Sub-Saharan Africa Lives in London In UK 10 years. Case 5: PMH. 1998 Registered with GP 2006 Seen by GP for hypertension 2007 Seen by Dermatology OPD for Molluscum contagiosum. Case 5: June 2008. Referred by GP to Gynaecology OPD

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Case 5

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  1. Case 5 45 year-old woman From Sub-Saharan Africa Lives in London In UK 10 years

  2. Case 5: PMH 1998 Registered with GP 2006 Seen by GP for hypertension 2007 Seen by Dermatology OPD for Molluscum contagiosum

  3. Case 5: June 2008 Referred by GP to Gynaecology OPD • Multiple vulval ‘warts’ • On direct questioning also admitted to: • weight loss • dysphagia • blurred vision

  4. Case 5: June 2008 OE: • Multiple pigmented vulval lesions • Molluscum contagiosum • White patches in the mouth

  5. Case 5: June 2008 Investigations: • Vulval lesions biopsied: VIN1/2. • Hb 12.1, WCC 4.4, lymphocytes 0.66 • HIV Antibody positive • CD4 35 cells/mm3 • Viral load 700,000 copies/ml

  6. Case 5: June 2008 Further course of illness: • Referred to gynaecological oncologist for VIN • OGD showed oesophageal candidiasis • Fundoscopy revealed CMV retinitis • Treated with • Antiretrovirals (Truvada/Nevirapine) • Oral septrin • IV ganciclovir • High dose fluconazole

  7. Case 5: summary 1998 Registered with GP 2006 Seen by GP for hypertension 2007 Seen in Dermatology OPD with molluscum contagiosum 2008 Seen in Gynaecology OPD with weight loss, oral candida and vulval warts HIV diagnosed: CMV retinitis CD4 35: VL 700,000

  8. Q: At which of her healthcare interactions could HIV testing have been performed? • When she registered with her GP? • When she was seen by her GP for hypertension? • When she was seen in Dermatology OPD? • Should she have been referred to GUM to see a trained counsellor before HIV testing?

  9. Who can test?

  10. Who to test? Who to test?

  11. Who to test?

  12. Who to test?

  13. Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

  14. At least 3 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 10 years earlier 1998 Registered with GP 2006 Seen by GP for hypertension 2007 Seen in Dermatology OPD with molluscum contagiosum 2008 Seen in Gynaecology OPD with weight loss, oral candida and vulval warts HIV diagnosed: CMV retinitis CD4 35: VL 700,000

  15. Who to test? 2008 Report on the global AIDS epidemic HIV prevalence (%) in adults (15–49) in Africa, 2007 Source: UNAIDS Global Report 2008, www.unaids.org

  16. Learning Points • This patient was at high risk of HIV as she comes from an area of high HIV prevalence • She had had numerous contacts with medical services over 10 years • She had previously presented on one recorded occasion with a condition closely associated with HIV infection • Because of her nadir CD4 of 35 she has an increased risk of potential problems despite control of her HIV now • She actually had an AIDS-defining condition at the time of diagnosis

  17. Key messages • Antiretroviral therapy (ART) has transformed treatment of HIV infection • The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity • UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection • UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence is>1/1000 as it has been shown to be cost-effective

  18. Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345

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