Diagnostic testing

HIV presents in a myriad of ways. How can a GP or Practice Nurse respond to the clues?


Retrospective reviews of GP records after new HIV diagnoses show that patients present in primary care with HIV-related conditions, but the significance is often missed.

The difficulty is that many of them are conditions commonly encountered in general practice and commonly viewed as harmless. These conditions may also respond to treatment.

The trusted ‘watch and wait’ approach is therefore not appropriate when HIV is a possible underlying cause. The clinician needs to be able to recognise, and then respond to, conditions associated with HIV.

Recognition of HIV indicator conditions

It is important for GPs to familiarise themselves with those conditions associated with HIV. See here a list of conditions that are associated with HIV infection.

The risk of underlying HIV is higher if:

- these conditions are unusually severe (eg multidermatomal shingles)

- they are difficult to treat (severe recurrent vaginal candida or seborrhoeic dermatitis)

- the patient has more than one HIV indicator condition eg CINII and/or a lower respiratory tract infection and/or unexplained thrombocytopaenia (so do review the records of patients presenting with an HIV indicator condition).

Strategies to seek supporting clinical evidence of HIV

When a patient presents with an HIV indicator condition, it is worth taking these steps to assess further.

You need to know which conditions are HIV-associated and you need to be able to recognise them.

i Ask the patient if they have weight loss, sweats or diarrhoea

ii Examine the patient’s mouth, skin and nodes

iii Review the medical record for the last 2-3 years looking for additional HIV-associated conditions

For more detailed information see Section 2 of HIV in Primary Care booklet. This is also available in the resources section.

Better late than never?

The diagnosis of patients with HIV indicator conditions is virtually always, by definition, late.  But you can avoid it becoming very very late by taking a proactive approach to patients presenting with HIV-associated conditions.

Association between virological, immunological, & clinical events and time course of untreated HIV  (Reproduced with permission from e-GP: e-Learning for General Practice, RCCP).

VL and CD4

As the graph shows, after the earliest weeks of infection, a patient will typically remain asymptomatic for several years. Then, as the number of CD4 cells (T helper cells – a type of white cell) falls, they become prone to the infections, cancers and other HIV indicator conditions.

The significance of late diagnosis of HIV is covered in the case for HIV testing , which you may already have seen. It is important that you work with your team so that they all understand the implications of late diagnosis. How to work with your team will be fully addressed in the sections Assess your team's leanrnig needs and Change practice in your team.

Communication tips with the symptomatic patient

The prospect of raising the subject of HIV with a patient presenting with, for example, hard to treat seborrhoeic dermatitis, may feel challenging - or you may even feel it is inappropriate. However there is a strong clinical imperative to overcome any barriers we may have to discussing HIV with our patients.

You need to be comfortable with two key stages:

- introducing the subject of HIV, as a possible cause for symptoms, into the consultation - when the patient doesn’t expect it

- assessment of the risk of HIV in an individual symptomatic patient

Ideas for introducing the subject of HIV

“The great majority of patients I see with recurrent vaginal thrush have no particular reason for it. However, rarely, it may indicate diabetes – I would recommend a test for this if you agree? Even more rarely, it might indicate HIV – have you ever had a test for this?… Have you ever wondered if you could be at risk? ….Could I ask you some questions to check?"

“Occasionally when I see someone with [this rash], it is because their immune system is not working well. One uncommon cause of this can be HIV. Have you ever wondered if you could be at risk of this? Could we talk about that in more depth?"

Patient response:

"Doctor are you trying to tell me I have HIV?"

Range of replies:

"No I am not. However it is important that I think of rare causes of conditions as well as common ones. It is my job not to miss HIV so I do raise this with many of my patients!"

"HIV is uncommon, but I don’t know if any individual patient might have it - so it is always best to talk it through to consider testing".

"HIV is so treatable these days I find myself asking a lot of patients about it – the most damaging HIV is undiagnosed HIV!".

Assessing the risk that a symptomatic patient might have HIV helps them understand that you are being objective rather than being judgmental or jumping to conclusions.

You can find more ideas for raising the subject of HIV in the Useful phrases document.

Assessment of risk in the symptomatic patient

Assessing the risk that a symptomatic patient might have HIV helps them understand that you are being objective rather than being judgmental or jumping to conclusions.

In addition, the process of assessing risk of HIV informs and educates patients about how HIV is and isn’t transmitted. If a patient is found to be at no apparent risk (even if HIV testing is still agreed on) it reinforces sexual health promotion messages if this is acknowledged ‘from what you have told me you have been good at protecting your sexual health’.

Finally, risk assessment helps that minority of patients already fearful that they might have HIV to be open with you and share their concerns.

An HIV test should be offered to most symptomatic patients, but assessment of risk ensures:

a)    the patient can see you are making no assumptions about their risk

b)    patients do not decline tests because they have assumed they are not at risk

Risk assessment is often an educational process for your patient and it may give you valuable clinical information.

Risk assessment includes a sexual history (including sex with partners from overseas). Ensure men are asked if they have ever had sex with another man. A history of injecting drug use or treatment overseas is also valuable. Country of origin should be considered in case the patient is from a very high prevalence area. For full guidance on sexual history-taking and risk assessment, see resources.

If you find no apparent risk for HIV, with the symptomatic patient it is good practice to offer a test anyway “from what you have told me there are no clear risks of HIV, however would you like a test anyway, so we can rule it out?”.

Risk assessment is discussed a little further in the next section, Opportunistic Testing for HIV.


 

Primary HIV infection: the diagnostic jackpot for GPs

Primary HIV infection (PHI), formerly known as HIV seroconversion illness, is a flu-like illness. Common symptoms include sore throat, fever and myalgia. Patients may also have a rash, diarrhoea and a range of other symptoms. Diagnosing a patient with PHI has fantastic clinical benefits:

•    They are at their most infectious, and transmission-on may be prevented.

•    They can be enrolled in the earliest possible care for HIV.

•    Partner notification is likely to be more successful, because the infection was so recent.

PHI is discussed in more detail in Section 2 of HIV in Primary Care booklet. This is also available in the resources section.

  Primary HIV infection - my registrar's story
Primary HIV infection - a flu-like illness – occurs just a few weeks after a patient has been infected with HIV.  I learned about this in a course I went on, and I remember thinking that it would be pretty difficult to pick up. However I was impressed by the advantages of diagnosing HIV at this earliest of all stages, with the benefits to the patient (as well as the potential to stop, or limit, transmission). Because our practice serves an area with a high prevalence of HIV I ran a clinical meeting on the subject. We included all our doctors and nurses because any of the clinical team can be involved in assessing sore throat and flu-like illnesses on the phone or face to face.

We agreed that we would raise the subject of HIV whenever possible in patients with such illnesses, but that we would always try to consider HIV when arranging tests for possible glandular fever.

We discussed how one might raise the subject of HIV when faced with a patient with such an illness and agreed on some phrases. My favourite is:

"There are a number of viruses that may cause a sore throat illness such as yours, and one of the commonest is flu. However a bit less commonly it can be caused by glandular fever. Have you heard of this? Shall we do a test? Even more uncommonly a cause can be HIV. Do you think you could have been at risk of this in the last couple of months? Could I ask you some questions to assess your risk? Would you like a test?"

Just a few months after we had this meeting my registrar saw a man aged about 35 who had a bad sore throat, myalgia and fever. He had been unwell for a week. My registrar managed to raise the subject of HIV and take a history to assess risk. She established her patient had had unprotected sex 2-3 weeks before with another man who he had just met in a club. He was surprised when she mentioned HIV but she helped him understand the value of testing. The HIV test showed him to be HIV antigen positive and antibody negative: ie primary HIV infection was confirmed. Her patient is doing extremely well and is relieved his infection was diagnosed so early.

My registrar got a big boost of confidence – I asked her to present the case to the team. One of our nurses pointed out that the consultation – including the sexual history – might equally well have been conducted on the phone. We reflected that, whatever our fears, our patients will often react reasonably calmly to a discussion about a difficult topic.


Return to Update yourself or view the next section Opportunistic testing

Did you know...

The transmission of HIV from an HIV-positive mother to her child during pregnancy, delivery or breastfeeding can be reduced to levels below 1% with effective interventions in developed countries, and to below 4% in resource poor settings (UNAIDS).

In resource poor settings mothers with HIV are advised to breast feed as the risks from bottle feeding in that environment are higher than the risk of HIV transmission.

Doctors