My patient SK is a 37 year old single mother – her kids are about 17 and 15 years old. I was aware she had divorced 7 or 8 years ago. SK works as a secretary in a secondary school. She was diagnosed with HIV 12 days after admission to intensive care with a severe atypical pneumonia. I know the consultant who was caring for her, and, as I had admitted her, we discussed her case some time after she had been transferred to the ward and was recovering. Because of the severity of her illness, and the apparent delay in diagnosis of her HIV, her consultant was reviewing her care in the hospital. I agreed we would also review our own records to see if we had missed any diagnostic opportunities.
In the 2 years prior to her hospital admission the patient had attended the practice on several occasions:
I was quite shocked when I realised that, with the benefit of hindsight, each and every one of SKs symptoms and conditions were likely to be HIV related. I am embarrassed to recall that at one point she and I shared a joke about how she was having ‘a run of bad luck’ with respect to her health. Even the episodes of contraceptive care might have presented an opportunity to discuss sexual health.
SK’s admission was stormy and she remained in hospital for over 5 weeks, during which time her kids were looked after by her sister. SK was not fit to return to work for over 4 months. She is now well established on antiretroviral therapy, has regained her original weight, and is feeling better than she has for a long time.
I am well aware that, had the practice generally been more proactive in offering HIV tests, we might have spared her that terrible, debilitating illness and prolonged admission. Her kids would not have gone through the horror of seeing their mum in ITU.
It was a crystal clear, adverse, significant event. We ran a clinical meeting on HIV and looked to see if we could find ways to increase HIV testing appropriately by both GPs and practice nurses. I was particularly keen to increase the use of HIV tests as a diagnostic tool, especially by doctors, when symptoms or conditions might be HIV related. I was also concerned to help all of us increase testing with asymptomatic people where there was some indication, because of course people diagnosed at an asymptomatic stage are likely to do so much better.
I think one of my colleagues had been pretty unsure about HIV testing in the past, but we were all shocked by this story and so made sure we overcame any obstacles to testing. I suppose I feel I owe it to SK not to let that happen to any other patients.
Our patient SK is a 37 year old single mother with two teenage kids. She works as a secretary in a school. I have got to know her quite well over the years, and was shocked when I heard that she was in intensive care with severe pneumonia.
When it turned out that this had been due to HIV, one of our GPs, Dr BB, used a clinical meeting to update us all on HIV and we reviewed SKs case. We learned that, in general, patients do much better if their HIV infection is picked up early before the damage to their immunity is too severe.
We concluded that opportunities had been missed by almost every doctor and nurse in the practice. Including me.
SK had consulted a practice nurse on four occasions – for repeats of oral contraception (2 occasions, 16 months and 5 months prior to her admission]. She had seen me about her recurrent vaginal candida. She had also had a cervical screening test and been found to have severe dyskariosis. None of the three of us practice nurses had been aware that HIV increases the risk of vaginal thrush and also of progression to cervical cancer and that, in a sense, this might have alerted us.
Me and my nurse colleagues found out quite quickly that there is no barrier to practice nurses offering HIV tests. In fact we found out that in areas with higher prevalence than here, schemes are being run where health care assistants offer HIV tests to newly registering patients! At least one of our doctors was pretty surprised when we pointed that out. We started to explore means of offering HIV tests in a range of clinical situations and have increased our testing substantially. We now review the cases of those women referred for colposcopy.
It wasn’t so much that I was scared in some way of offering HIV tests before (though some of my colleagues were). It was more a question of ‘out of sight out of mind’. I am happy we have all changed our practice and taken this on board.