A Practical Guide to HIV on World AIDS Day

1. A Practical Guide to HIVonWorld AIDS Day Ria Daly ST3 GU/HIV Medicine

3. UK • Public knowledge of HIV in the UK is declining • Lack of understanding about HIV and it’s relevance in the UK • For people to respect and protect themselves and others, they need to understand the facts and reality of HIV in the UK. • International • “Universal Access and Human Rights” • Universal access to information, prevention and testing for people at risk of infection.

4. What should you know about HIV? • HIV – Current UK facts and figures • HAART – Overview of HAART and it’s impact • HIV testing • What the guidelines say • Who should be tested? • How do I test? • Where to turn when the result is positive • The Law and HIV

5. 51 ♂ • Zimbabwe UK 2005 PC: SOB 3/52 dry cough Fever Myalgia PMH 6/12 persistent skin rash DH Amoxicillin SH Wife & 3 children Travels with work

8. Initial Investigations

20. CXR

21. What should you know about HIV? • HIV – Current UK facts and figures • HAART – Overview of HAART and it’s impact • HIV testing • What the guidelines say • Who should be tested? • How do I test? • Where to turn when the result is positive • The Law and HIV

22. HPAHIV in the United Kingdom: 2009 Report 83,000 infected at the end of 2008 27% of people with HIV in the UK are unaware of their infection

24. Prevalence of previously undiagnosed HIV infection, UK: 2007 Unlinked anonymous prevalence monitoring

25. HPAHIV in the United Kingdom: 2009 Report 7,298 new diagnoses New diagnoses among MSM remained high in 2008

27. HPAHIV in the United Kingdom: 2009 Report • Four out of every five MSM probably acquired infection in the UK. • Heterosexually acquisition in the UK • 740 in 2004 → 1,130 in 2008. • Preliminary data for the first six months of 2009 1 in 5 MSM &1 in 10 heterosexuals newly diagnosed with HIV were likely to have acquired their infection within the last six months.

29. Why is early diagnosis important? • Late diagnosis • Increased morbidity and mortality • Impaired response to HAART • Increased cost to health services • 55% patients were diagnosed with a CD4 <350 at diagnosis in 2008, the threshold at which treatment is recommended to begin • 73% patients who died from HIV in 2008 had presented late • Many late presenters have been recently seen by health care professionals

30. Natural Course of HIV Infection CD-4 count /ml HIV RNA / ml 1000000 Relativelatency 1000 HIV RNA CD-4 cells 500000 500 350 200 0 0 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 13 Months Years after HIV infection

32. BHIVA Mortality Audit 2006

33. Early Diagnosis to Prevent Transmission • Knowledge of HIV status is assoc with reduced risk behaviour • Estimated HIV related lifetime cost per diagnosed individual £280,000 to £360,000 • Modelling has suggested that in the US 50% of new infections occur from undiagnosed individuals • Preventing 3,550 HIV infections probably acquired in the UK, and subsequently diagnosed in 2008, would have saved over £1.1 billion in future HIV-related costs

35. What should you know about HIV? • HIV – Current UK facts and figures • HAART – Overview of HAART and it’s impact • HIV testing • What the guidelines say • Who should be tested? • How do I test? • Where to turn when the result is positive • The Law and HIV

36. HAART

38. HAART • Highly Active Antiretroviral Therapy • 1996 • Suppress Viral Load & Increase CD4 counts • Combination therapy • More effective, better tolerated, simplified dosing • Decreased mortality

39. Late 90s

40. Late 90s Now

41. HIV-infected individuals are now living longer 25000 100000 20000 80000 15000 60000 AIDS cases and deaths Living with HIV 10000 40000 5000 20000 0 0 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year AIDS Deaths Living with HIV EUROHIV. HIV/AIDS Surveillance in Europe: End-year report 2004, No. 71available at http://www.eurohiv.org/reports/index_reports_eng.htm (accessed April 2006)

42. Antiretroviral Therapy Cohort Collaboration Lancet 2008 • Life expectancy in high income countries • >43,000 treatment naïve patients initiated on cART • Decreased to 59.8% if CD4 <100cells/ul • Decreased to 66.4% if IVDU

43. HAART • Must be taken on time!

44. What should you know about HIV? • HIV – Current UK facts and figures • HAART – Overview of HAART and it’s impact • HIV testing • What the guidelines say • Who should be tested? • How do I test? • Where to turn when the result is positive • The Law and HIV

45. TESTING: • What the guidelines say • Who should be tested? • How do I test? • Where to turn when the result is positive

46. BASHH, BHIVA & BISGuidelines for HIV Testing 2008 Aims • Facilitate increase in HIV testing in ALL health care settings • Reduce the proportion of undiagnosed HIV • Benefit individual and public health • Encourage ‘normalisation’ of testing • Recognise the need for a newly diagnosed individual to be immediately linked to HIV treatment and care • Maintain confidentiality within any health care setting

47. Opportunistic screening 2 per 1,000 population recommended to expand HIV testing in the local population 43 English Local Authorities in 2008 Testing patients with ‘clinical indicator diseases’

48. Who should be tested? Opt Out’ for: • All patients attending GUM or sexual health clinics • All women attending antenatal services • All women attending termination of pregnancy services • All patients registering with drug dependency programmes reporting a history of injecting drug use • All patients diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and Lymphoma

49. Any other patients presenting for healthcare where HIV enters the differential diagnosis including primary HIV infection • All individuals known to be from a high prevalence country • MSM • All men and women who report sexual contact with individuals from areas of high HIV prevalence, abroad or in the UK.

50. Clinical Indicator Diseases