HIV Testing patterns and missed opportunities for diagnosis P. Read, D. Armstrong-James, W. Tong, J. Fox Background 2008 National guidelines published to increase HIV testing to reduce undiagnosed infection Onward transmission Late stage diagnosis (CD4<200) Associated with high mortality (BHIVA Audit 2007) Accounts for 40% new diagnoses Guys and St Thomas Guidelines recommend Increased HIV testing in non-gum settings A lot of focus on community and A&E HIV test those with HIV indicator conditions
Objectives Describe HIV testing practices Guys and St Thomas Hospital pre-implementation of guidelines For HIV positive tests: explored missed opportunities for HIV testing investigated whether National guidelines would have led to earlier diagnosis
Method All HIV tests performed at Guys and St Thomas lab in 2008 Case note review of HIV-positive results: Previous presentations to Guys and St Thomas Evidence of HIV indicator diseases Tests from known HIV positives excluded Results : location of HIV Testing 41095 HIV tests performed on 36392 individuals 363 HIV positive results (1% detection rate) Location No. tests No. positives % positive GUM 18872 182 0.96% Antenatal 6197 34 0.54% GP (cannot excl antenatal) 5746 68 1.12% Outpatients (excl Harrison wing) 5303 26 0.50% Occ. Health 2040 1 0.05% Inpatients 1225 34 2.77% Family planning 1221 18 1.47% HIV screening is cost effective where prevalence > 0.05 per cent (Sanders NEJM 2005)
Request form reviewed GP diagnoses n=68 N=28 no details on form 23/40 (58%) screening 13 sexual health screen 4 IDU 4 antenatal 1 Needlestick 17/40 (43%) indicator diseases 5 Haematological Neutropenia Thrombocytopenia Lymphopenia 3 possible seroconversion 3 Lymphadenopathy 4 viral hepatitis B or C 1 Weight loss 1 Herpes Zoster 1 Chronic diarrhoea I.e. GPS are thinking of HIV and indicator disease Outpatient HIV tests 26/5303 (0.5%) positive Reason for test not explored Team No Tests No. pos Fertility 1895 5 ENT 27 4 Drug team n/a 4 Gynae 692 3 Haem 272 3 Chest 99 3 Renal 1253 1 Rheum 30 1 Police n/a 1 Mental Health n/a 1 Team No Tests No. pos A&E 250 0 Derm 88 0 Gastro 83 0 Oncology 54 0 Endocrine 23 0 Ophthal 22 0 Urology 16 0 Neurology 15 0 Cardiology 7 0 Other 507 0
New HIV positive -outpatients 8 infections not new diagnoses 7/ 17 (41%) attended Guys and St Thomas in past yr All had indicator diseases: All had lymphopenia (mean CD4 190) TB Persistent CIN 2 Generalized Molluscum Severe psoriasis Recurrent bacterial chest infections I.e. missed opportunity Do patients get HIV result? 1/26 not documented received diagnosis A&E: patient had been contacted by phone and was seeking care elsewhere.
Inpatient diagnoses n=34 Total notes reviewed 29 Age median (Range) 43 ( 21-74) Risk group 15 (51%) Heterosexual (12 BA,3 BC) - 12 (41%) women - 3 (10%) men 11 MSM (38%)( 100% Caucasian) 2 IDU (7%) CD4 count Median 64 (Range 4-760) Stage of HIV infection: AIDS defining Symptomatic HIV disease Asymptomatic (from HIV) Seroconversion illness 18/29 (62%) 6/29 3/29 2 Admission duration mean 34 days (Range 0-324) 69 days in ITU/HDU Cost of admission mean 36,625 (Range 3,310-223k) Time admission to test mean 2.31 days (0-14 days) Previous attendances of inpatient diagnoses 12/29 (41%) had previous GSTT attendance in past year 10/12 (83%) had HIV indicator conditions in previous visits Pneumonia, Ca Cervix, lymphopaenia Lymphopaenia (Raised TP, Fe-anaemia) Lymphopaenia (Fe-anemia, multiple abscesses) Pneumonia Pneumonia & Lymphopaenia VZV and aggressive HPV VAIN/CIN CIN III Neutropaenia & dementia Hep C, weight loss, psychosis
Conclusions Low number of tests in outpatient settings high detection rate Suggests more tests may detect more infection testing due to indicator diseases not assessed Opportunities for earlier diagnoses identified 41% inpatient and 41% outpatient diagnoses had attended GSTT in past year most had retrospective evidence of HIV indicator disease In and out patient diagnoses were late stage In patients had multiple pathologies, long admissions Diagnosis occurred early in admission Long expensive admissions are often avoidable Recommendations Findings support urgent implementation of National guidelines Wider hospital audience needs to be involved Missed opportunity for testing = governance issue Trust governance committee Lambeth PCT preventing late diagnosis key priority Promoted HIV indicator diseases to rest of hospital Other possibilities: laboratory or radiology reports with indicator conditions to suggest an HIV test haematology reports to provide local HIV prevalence In order for roll out to be a successall positive results must be acted upon and documented
Acknowledgements GUM & HIV: P. Read Virology: D. Armstrong-James W. Tong Lambeth PCT: M Ruf