A Practical Guide to HIV on World AIDS Day

A Practical Guide to HIVon

World AIDS Day

Ria Daly

ST3 GU/HIV Medicine

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.

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

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

Initial assessment

8/11/09

T38.7°c

Clear chest RR22

Type 1 RF

Dry macular lesions

ΔΔCAP

Swine Flu

Sarcoidosis

Bloods + BC

H1N1

IVI

Co-amoxiclav

Erythromycin

Initial assessment

8/11/09

T38.7°c

Clear chest RR22

Type 1 RF

Dry macular lesions

ΔΔCAP

Swine Flu

Sarcoidosis

Bloods + BC

H1N1

IVI

Co-amoxiclav

Erythromycin

Med SpR

8/11/09

No previous HIV test

CXR

Initial InvestigationsHb 10.9

WCC 6.8

lym 0.8

neut 5.7

Plt 348

Na 142

K 4.2

Ur 7.9

Cr 89

TP 68

Alb 28

Bil 7

Alk 48

ALT 30

CRP 153

Initial assessment

8/11/09

T38.7°c

Clear chest RR22

Type 1 RF

Dry macular lesions

ΔΔCAP

Swine Flu

Sarcoidosis

Bloods + BC

H1N1

IVI

Co-amoxiclav

Erythromycin

Med SpR

8/11/09


CXR: bilateral diffuse shadowing

Δ Bilateral Severe CAP

ΔΔ Atypical

PCP

Swine flu

Consent for HIV test

D/W Micro•Co-trimoxazole•Tamiflu•PCR PCP

Initial assessment

8/11/09

T38.7°c

Clear chest RR22

Type 1 RF

Dry macular lesions

ΔΔCAP

Swine Flu

Sarcoidosis

Bloods + BC

H1N1

IVI

Co-amoxiclav

Erythromycin

Med SpR

8/11/09


CXR:bilateral diffuse shadowing


ΔΔ Atypical

PCP

Swine flu


D/W Micro•Co-trimoxazole•Tamiflu

ITU

8/11/09

Respiratory distressFi02 21% pH7.22

pC02 3.3 p02 6.7

T38.9°c

HIV test sent

CPAP

Initial assessment

8/11/09

T38.7°c

Clear chest RR22

Type 1 RF

Dry macular lesions

ΔΔCAP

Swine Flu

Sarcoidosis

Bloods + BC

H1N1

IVI

Co-amoxiclav

Erythromycin

Med SpR

8/11/09


CXR:bilateral diffuse shadowing


ΔΔ Atypical

PCP

Swine flu


D/W Micro•Co-trimoxazole•Tamiflu•PCR PCP

ITU

8/11/09

Respiratory distress

Fi02 21% pH7.22

pC02 3.3 p026.7

T38.9°c

HIV test sent

CPAP

ID

9/11/09

No Hx TB

6/12 discoid erythematous rash

Destructive nail changes

No candida/

lymphadenopathy

Chase HIV

Bronchoscopy for PCP

Urgent CD4

Prednisolone

GUM/ITU

10/11/09

HIV positive Discussed diagnosis

Expressed wish not to inform wife

Baseline bloods

GUM/ITU

10/11/09



Baseline bloods

ITU

11/11/09

Ventilated ‘if confirmed HIV positive we must inform wife despite patient’s wishes’

Bronchoscopy

GUM

10/11/09



Baseline bloods

ITU

11/11/09

Ventilated ‘if confirmed HIV positive we must inform wife despite patient’s wishes’

Bronchoscopy

ITU

12/11/09

Tracheostomy

CRP 29

Sputum IF neg

Blood PCR +ve PCP

Stop co-amoxiclav

GUM

12/11/09

Will D/W patient and family once improved sufficiently to converse

GUM

13/11

Viral screen neg

Communicate via writing

CD4 10 cell/ul

Does not wish to disclose

Wife is HCW

Agrees to disclosure if deteriorates

GUM

13/11

Viral screen neg


CD4 10 cells/ul


Wife is HCW


13-17/11 Improving

Ward

IV co-trimoxazole

GUM

13/11

Viral screen neg


CD4 10 cells/ul


Wife is HCW


13-17/11 Improving

Ward

IV co-trimoxazole

16/11 Dermatology ΔΔ Pityriasis Versicolor

Tinea corporis

Psoriatic nail disease/onychomycosis

GUM

13/11

Viral screen neg


CD4 10 cells/ul


Wife is HCW


13-17/11 Improving

Ward

IV co-trimoxazole


Tinea corporis


17-23/11 VL 237864 copies/ml

Support from HA

Disclosed to wife

THT

GUM

13/11

Viral screen neg


CD4 10 cells/ul


Wife is HCW


13-17/11 Improving

Ward

IV co-trimoxazole


Tinea corporis


17-23/11 VL 237864 copies/ml

Support from HA

Disclosed to wife

THT

23/11 IV-PO co-trimoxazole

Reducing dose prednisolone

See in GU clinic to commence HAART

Derm F/U Δ psoriasis






How do I test?


The Law and HIV

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

http://www.techgadgets.in/images/health-protection-agency.jpg

Estimated number of adults (15-59 years) living with HIV (both diagnosed and undiagnosed) in the UK: 2008

6,550

4,5505,450

1,200550450 150

13,850

24,350

2,1502,250

4,0502,850

8,950

0

5,000

10,000

15,000

20,000

25,000

MSM Heterosexualmen born in

Africa

Heterosexualwomen born in

Africa

Heterosexualmen born in

UK/elsewhere

Heterosexualwomen born inUK/elsewhere

Injecting druguser men

Injecting druguser women

Es

tim

ate

d n

um

be

r o

f p

eo

ple

liv

ing

HIV

Diagnosed

Undiagnosed

Total = 77,550 (73,000 - 83,300)Excludes 5,450 HIV infections among individuals outside the 15-59 years age range

MESH Department - Centre for Infections

Prevalence of previously undiagnosed HIV infection,

UK: 2007

Unlinked anonymous prevalence monitoring

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

London Elsewhere in UK UK overall

Pre

va

len

ce

MSM

Heterosexuals - sub-Saharan African-born

Heterosexuals - UK-born

Heterosexuals - born elsewhere

http://www.cambridge-water.co.uk/uploads/images/gallery_images/504.jpg


7,298 new diagnoses

New diagnoses among MSM remained high in 2008

New HIV and AIDS diagnoses, people living with diagnosed HIV, and deaths, among HIV-infected people,

UK: 1999-2008

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Ne

w H

IV a

nd

AID

S d

iag

no

ses

an

d d

ea

ths

.

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Pe

op

le li

vin

g w

ith d

iag

no

sed

HIV

infe

ctio

n

.

Numbers with diagnosed HIV infection

HIV diagnoses

AIDS diagnoses

Deaths



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.

Number of new HIV diagnoses¹ by prevention group², UK: 1999-2008

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Ne

w H

IV d

iag

no

ses

MSM

Heterosexual contact in the UK

Heterosexual contact abroad

IDU

Blood product recipients

Mother-to-child transmission

¹ Numbers will rise as further reports are received, particularly for recent years² Adjustments made for missing information relating to patient exposure


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 begin73% patients who died from HIV in 2008 had presented lateMany late presenters have been recently seen by health care professionals

500000

Natural Course of HIV Infection

1000

0

500

1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 13

Months Years after HIV infection

Relative latency

CD-4 cells

HIV RNA

200

350

CD-4 count /ml HIV RNA / ml

1000000

0

BHIVA Mortality Audit 2006

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

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

Estimated late diagnosis of HIV infection by prevention group among adults aged ≥15 years, UK: 2008

Number diagnosed = 2,760 1,630 2,950 170 7,218

20%

44%

36%

30% 32%

43%

65%61%

52%55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MSM Heterosexual men Heterosexual women Injecting drug users Overall

Pe

rce

nta

ge

dia

gn

os

ed

late

<200

<350

CD4 cell counts <200 cells/mm³ within three months of diagnosis







How do I test?


The Law and HIV

HAART

Highly Active Antiretroviral Therapy

1996

Suppress Viral Load & Increase CD4 counts

Combination therapy

More effective, better tolerated, simplified dosing

Decreased mortality

Late 90s

Late 90s Now

HIV-infected individuals are now living longer

0

5000

10000

15000

20000

25000

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004Year

AID

S c

ases

an

d d

eath

s

0

20000

40000

60000

80000

100000

Livin

g w

ith H

IV

AIDS Deaths Living with HIV

EUROHIV. HIV/AIDS Surveillance in Europe: End-year report 2004, No. 71 available at http://www.eurohiv.org/reports/index_reports_eng.htm (accessed April 2006)

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/ulDecreased to 66.4% if IVDU

Life expectancy (years, adjusted)

1996-1999 2000-02 2003-2005

At age 20 36.1 41.2 49.4

At age 35 25.1 30.1 37.3

Percent surviving from 20-44 years

75.5% 79.5% 85.7%

HAART

Must be taken on time!






How do I test?


The Law and HIV

TESTING:

What the guidelines say


How do I test?


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

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’


Opt Out’ for:All patients attending GUM or sexual health clinicsAll women attending antenatal servicesAll women attending termination of pregnancy servicesAll patients registering with drug dependency programmes reporting a history of injecting drug useAll patients diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and Lymphoma

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.

Clinical Indicator Diseases

http://www.who.int/hiv/pub/en/

Do I need to counsel my patient before doing a test?

NoPre test counselling is no longer requiredHIV is a treatable conditionMost people in the UK remain fit and well on treatmentWe need to make testing easier to decrease the number of people living with undiagnosed HIV (and possibly unknowingly infecting others)All doctors, nurses and midwifes should be able to obtain informed consent

Pre test discussion

- Benefits of testing to the individual

- Window period and whether repeat testing is needed

- Details of how the result will be given

Written consent is discouraged

What to do if the result ispositive?

• Know what the next steps will be before telling the patient

• Involve your friendly GU team!

• Consider involving us pre-test in high risk patients






How do I test?


The Law and HIV

The Law and HIV

Reckless transmission

9 convictions in UK

Intentional transmission

No successful prosecution

www.cps.gov.uk

What is the position on disclosure to third party?

• BHIVA briefing paper 2006

• DOH: ‘Confidentiality and Disclosure of patient information: HIV and STIs 2006

• Confidentiality v Duty of Care

• ‘you may disclose information to a known sexual contact of a patient with HIV where you have reason to think that he has not informed that person, and cannot be persuaded to do so…you should tell the patient before making the disclosure...justify your decision to disclose information’

• ‘you must not disclose information to others who have not been, and are not at risk of infection’

GMC. Serious Communicable Diseases Oct 1997

• ‘a therapeutic relationship with the patient needs to be maintained and time is often required to facilitate patient directed disclosure. This is vital to prevent the patient feeling alienated and further contact being lost, to maintain the well being of the partner and in the interests of public health’

BHIVA 2006

• ‘’failure to maintain confidentiality may give rise to legal liability’ GMC

• Breaching confidentiality:Significant risk taking behaviour

Patient must be well informed of risks of non disclosure and support offered

Index patient has no intention to inform

Sufficient time

Case law for reckless transmission, not for non-disclosure to third party.

Summary

• Increase awareness & testing

• No need for counselling

• Positive outlook for new diagnosis if early

• Compliance with HAART is paramount

• Contact us!

Thank You for Listening

Any questions?

References1. HIV in the United Kingdom: 2009 Report http://www.hpa.org.uk/2. BHIVA 2005-6 mortality audit www.bhiva.org/files/file1001379.ppt3. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV

from persons aware and unaware that they are infected with thevirus in the USA. AIDS 2006;20:1447–50.

4. Vernazza P,Hirschel B, Bernasconi E et al. An HIV-infected person onantiretroviral therapy with completely suppressed viraemia (‘effectiveART’) is not sexually infectious [French]. Bull Méd Suisses 2008;89:165–9.

5. Sanders GD, Bayoumi AM, Sundaram V et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy.New Engl J Med 2005;352:570–85.

6. British Association for Sexual Health and HIV (BASHH), British HIVAssociation (BHIVA) and British Infection Society (BIS) Guidelines forHIV Testing (Version3.8 21/5/08)

7. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies Lancet, 372: 293 -99.

http://www.hpa.org.uk/

http://www.bhiva.org/files/file1001379.ppt

A Practical Guide to HIV on World AIDS Day

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