HIV testing made easy

All patients with an 'indicator disease' should be tested, regardless of their perceived risk.

Mouth conditions such as oral candidiasis may indicate HIV (Photograph: St Mary's Hospital Medical School / Science Photo Library)
Mouth conditions such as oral candidiasis may indicate HIV (Photograph: St Mary's Hospital Medical School / Science Photo Library)

A recent audit in Sheffield has shown that almost half of newly diagnosed HIV infections were diagnosed late. This was classified as a CD4 count <250 cells/microlitre, indicating impaired immunity and risk of opportunistic infections. Over one in five patients had been managed by either their GP or secondary care in the 12 months before diagnosis with an indicator disease that should have prompted HIV testing.1

Late diagnosis of HIV results in increased mortality, impaired response to treatment, increased cost to healthcare services and increased transmission risk. A national audit by the British HIV Association (BHIVA) showed that 24 per cent of deaths occurring amongst HIV positive individuals in the UK in 2006 were directly attributable to the diagnosis of HIV being made too late for effective treatment.2

The two biggest barriers to testing appear to be stigma and lack of confidence. This article aims to make HIV testing easier by discussing some misconceptions and encouraging 'normalisation' of testing. HIV testing in someone with an indicator disease should be viewed in the same way as a glucose test for someone with symptoms of diabetes.

Understanding HIV
HIV can affect anyone who has been sexually active. It usually takes several years to become symptomatic. HIV positive patients who start treatment at an appropriate time have a near-normal life expectancy.

Current treatment for HIV is well tolerated and sometimes can be taken as a simple daily tablet. People with HIV can still have an active sex life and children as vertical transmission can be virtually abolished.

Although rates of HIV are still highest in black African patients and men who have sex with men, an increasing number of white heterosexual patients are also HIV positive.

CONDITIONS THAT CAN INDICATE HIV
Respiratory
  • Bacterial pneumonia
  • Lung cancer
  • TB
Neurological 
  • Aseptic meningitis/encephalitis
  • Peripheral neuropathy
Dermatology
  • Severe or recalcitrant seborrhoeic dermatitis
  • Severe or recalcitrant psoriasis
  • Multidermatomal or recurrent herpes zoster
Gastroenterology 
  • Oral candidiasis and severe oral ulceration
  • Chronic diarrhoea of unknown cause
  • Weight loss of unknown cause
Gynaecology 
  • Vaginal intraepithelial neoplasia
  • CIN grade 2 or above
Haematology 
  • Any unexplained blood dyscrasia including
    thrombocytopenia, neutropenia, lymphopenia
  • Lymphoma
Other
  • Lymphadenopathy of unknown cause
  • Pyrexia of unknown origin
  • Any STI

When should we test?
Some of the most common manifestations of late HIV infection are skin disorders, mouth conditions and weight loss - all commonly seen by GPs (see box above).

Primary HIV infection should be considered when patients present with fever, rash (typically maculopapular), myalgia, pharyngitis and headache. Seroconversion illness occurs in approximately 80 per cent of individuals typically two to four weeks after infection.

All symptoms resolve spontaneously within two to three weeks but infection may not be detected at this point due to the delay in producing antibodies.

If testing is negative and seroconversion suspected the test must be repeated at four weeks. Modern fourth generation HIV tests are usually positive within four weeks of symptom onset, often earlier. It is rare for seroconversion to be delayed for three months.

As part of the pre-test discussion, tell the patient you are performing a HIV test as part of routine bloods to investigate their current problem.

Verbal consent is enough. There is no need for lengthy pre-test counselling, unless the patient requests it, or even a sexual history.

If the result is positive a full history will be taken when the patient is referred to a HIV specialist team.

Patients should be told about the benefits of testing and details of how the result will be given to them.

If positive, it means treatment can begin at an appropriate time preventing the patient getting ill. Awareness of a positive status can lead to risk reduction and reduced transmission.

In pregnancy it allows informed choices to reduce vertical transmission. If negative, the test will have ruled out one potential cause of the patient's symptoms and could eliminate needless anxiety.

Undertaking the test
Send one serum sample. The recommended first line assay is one which tests for the HIV antibody and the p24 antigen (a marker of the HIV virus which can be detected before the HIV antibody is produced). These are known as fourth generation tests and are widely available in the UK.

With regards to life insurance, questions about previous HIV testing should no longer be asked. Applicants should declare any positive results, as would be the case with any other medical condition.3

There are companies that provide HIV positive individuals with life insurance so mortgages are still an option.

In the event of a positive result - do not panic. Ensure you are armed with some basic knowledge as outlined above and consult the resources below.

Contact your local HIV specialists if you are unsure of what else to say or who to refer to. These are normally GUM or infectious disease physicians.

  • Dr Sutton is a specialist registrar in GUM at the Royal Hallamshire Hospital, Sheffield

Resources

References
1. Sutton N, Gupta N, Partridge D, et al. Missed opportunities to diagnose HIV in late presenters. HIV Med 2010; 11 (Suppl s1): 43.

2. BHIVA Audit and Standards Subcommittee. Mortality audit 2005-6.

3. Association of British Insurers. Statement of best practice on HIV and insurance. October 2004.

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