Case 4: HIV testing – expert comment from Nadia Ahmed, Emily Chung and Simon Edwards

DSC_0663Thanks to everyone for a great discussion about Rachel Brown who was brought to hospital by her sister after developing neurological signs and symptoms. Due to the likely diagnosis of PML, the key question was when to test for HIV and how to navigate the tricky issue of consent. Thanks to students and doctors for some really important insights, and for highlighting useful guidelines.

You can see the highlights of the discussion on Twitter in the storify.

Late diagnosis of HIV is associated with a significantly increased risk of morbidity and mortality. Understanding who and when to test is key to reducing avoidable ill health associated with HIV

This week’s question setters were Dr. Nadia Ahmed and Dr. Emily Chung, HIV and sexual health specialist registrars, Mortimer Market Centre, Central and North West London Foundation Trust. Our expert was Dr. Simon Edwards, HIV consultant physician, Mortimer Market Centre, Central and North West London Foundation Trust

Information available at the start of the week:

Miss Rachel Brown, a 45 year old woman originally from Ghana, is brought to hospital by her sister who is her next of kin. She has been behaving strangely for one week: she has not using her right arm while performing daily activities, and is now having difficulty walking. She has lost 10kg in weight over the last 6 months. She has hypertension, for which she takes amlodipine, and has had an anaphylactic reaction to penicillin in the past. Her father had a myocardial infarction aged 49. Rachel lives with her sister and is normally fully independent, working as a childminder. Rachel has never smoked, and drinks alcohol only very occasionally.

Her observations are:

  • Temperature: 37.0 C, HR 98bpm, RR 20/min, GCS 14/15, BP 170/92mmHg, BM 5.2mmol/L, Sats 98% on air.

Examination shows:

  • A: airway clear
  • B: air entry bilaterally, no crepitations or wheeze
  • C: bounding pulse, warm peripheries, capillary refill < 2 seconds, heart sounds normal
  • D: confused with slurred speech, GCS E4 V4 M6, AMT 1/10 (knows name) pupils equal and reactive. Right arm and leg shows increased tone, power 4/5 and brisk reflexes. Left arm and leg normal. Nystagmus and intention tremor on the left. Unable to cooperate with coordination and sensation
  • E: abdomen soft, no masses, suprapubic tenderness, but no guarding or rebound, bowel sounds present

Investigations reveal:

  • Bloods: Hb 90g/L*, WCC 11 x109/L (neutrophils 8, lymphocytes 1), Platelets 90 x109/L, Sodium 141mmol/L, Potassium 3.9mmol/L, Urea 5.7mmol/L, Creatinine 95µmol/L, Albumin 40g/L, ALT 22IU/L, AST 35IU/L, ALP 45IU/L, Bilirubin 14µmol/L, CRP 66
  • CXR: no focal consolidation
  • Urine dip: protein +, blood +, leucocytes -, nitrites –
  • CT head without contrast: non-specific white matter changes in the left cerebral hemisphere
  • MRI brain: white matter changes: multifocal, asymmetric periventricular and subcortical involvement, with no mass effect

*some hospitals are still using g/dL as units for Haemoglobin in which case the result would be 9.0 g/dL

Question prompting discussion on Twitter: How should we proceed to test her for HIV? 

 

Expert comment

Key points:

1. Late diagnosis of HIV is associated with a significantly increased risk of morbidity and mortality. Understanding who and when to test is key to reducing avoidable ill health associated with HIV.

2. Awareness of HIV infection in the setting of opportunistic infection allows prompt initiation of HIV therapy which can significantly improve outcomes in many opportunistic infections. It is important for all doctors to have a good understanding of the indicator conditions that should immediately prompt consideration of HIV testing.

3. In accordance with the Mental Capacity Act 2005 a person should be helped to make the decision to have or not have a HIV test, if at all possible. If they lack capacity to make this decision but the incapacity they are suffering is temporary (eg delirium), tests or treatments should be postponed until the individual is able to decide for themselves. This is the case unless there is an urgent need for the intervention.

4. If there is an urgent need to test for HIV because this would alter management and clinical outcomes, then HIV testing can occur without consent, as decided by the medical team in the best interests of the patient. At this point specialist input should be sought for advice on testing and management.

Resources:

Dr Nadia Ahmed, Dr Emily Chung (HIV and sexual health specialist registrars, Mortimer Market Centre, Central and North West London Foundation Trust) and Dr Simon Edwards (HIV consultant physician, Mortimer Market Centre, Central and North West London Foundation Trust) say:

Late diagnosis of HIV is associated with a significantly increased risk of morbidity and mortality. Understanding who and when to test is key to reducing avoidable ill health associated with HIV. HIV disproportionately affects Black African communities so NICE guidelines advocate more widespread testing in these populations. There is also guidance on increasing HIV testing in men who have sex with men, of whom approximately 1 in 10 are now HIV positive in London. An awareness of the local prevalence is useful and is published by the HPA.

Rachel Brown, our patient, presented with PML, an opportunistic infection (OI). The MRI findings are typical and to confirm the diagnosis CSF analysis or brain biopsy to look for JC virus should be performed. It is quite possible that Rachel may have other CNS infections concomitantly and these should be considered and excluded as part of the differential of someone who is profoundly immunosuprressed, such as meningitis (including TB and cryptococcal), encephalitis (HSV, CMV and HIV), cerebral toxoplasmosis, and primary CNS lymphoma. Clinical presentation of CNS OIs include seizures, meninigits, encephalitis, confusion and coma. The essential investigations including brain imaging (preferably MRI) and, where possible examination of CSF fluid to look for all above diagnoses. OIs have a high morbidity and mortality and early diagnosis is essential to improve outcome. In the setting of advanced HIV infection, multiple opportunstic infections can occur at the same time: a challenge for the diagnostician!

HIV and its’ complications can present to any medical or surgical speciality so it is important for all doctors to have a good understanding of the indicator conditions that should immediately prompt consideration of HIV testing. These include tuberculosis, lymphoma, hepatitis B and C, recurrent bacterial infection, unexplained blood dyscrasia, unexplained weight loss, unexplained diarrhoea, and pyrexia of unknown origin. For a comprehensive list of indicator conditions please refer to the national guidelines for HIV testing. Certain indicator diseases are more common than others, but they all remain an indicator disease for a possible underlying diagnosis of HIV. HIV testing should be offered as it may save a life.

Awareness of HIV infection in the setting of OI allows accurate diagnosis of OI with appropriate treatment and prompt initiation of HIV therapy which can significantly improve outcomes through improving immune system function and preventing occurence of further OIs. Knowledge of HIV status is essential before HIV therapy is initiated.  It is important to diagnose OI promptly to improve outcome but not always possible to obtain informed consent. In accordance with the Mental Capacity Act 2005 a person should be helped to make the decision to have or not have a HIV test, if at all possible. If they lack capacity to make this decision but the incapacity they are suffering is temporary (eg delirium), tests or treatments should be postponed until the individual is able to decide for themselves. This is the case unless there is an urgent need for the intervention, or unless it is expected that the delirium or clinical presentation will not improve, unless OI or HIV is treated.

If there is an urgent need to test for HIV because this would alter management and clinical outcomes, then HIV testing can occur without consent, as decided by the medical team in the best interests of the patient. In this case, where HIV infection and PML are the likely diagnoses, clinical improvement will only occur if HIV is treated. Initiation of antiretroviral therapy is paramount in this person, therefore it would be reasonable to test for HIV without consent, for this reason. At this point specialist input should be sought for advice on testing and management.

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One response to “Case 4: HIV testing – expert comment from Nadia Ahmed, Emily Chung and Simon Edwards

  1. Pingback: Autumn quclms term starts 9th September | Question of the week at UCL Medical School·

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