Oxford Handbook of Genitourinary Medicine, HIV, and Sexual
Health (2 edn)
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HIV pre-test discussion
UK surveillance data show that ~1/3rd of HIV infections in adults remain undiagnosed and that ~25% of newly diagnosed individuals have a CD4 count <200cells/μL and even with treatment have a significantly higher mortality than those diagnosed when CD4 count >200cells/μL. HIV testing has been largely confined to individuals requesting the test. There is a need to increase the offer and uptake of testing, necessitating a shift from in-depth counselling to a brief discussion with normalization of testing.
Testing should routinely be offered to the following patients:
GUM/sexual health clinic attendees
women antenatally and those seeking terminations
IV drug users
those with TB, HCV, or HBV
men and women who have high risk sexual contact
those undergoing transplantation or dialysis, or blood donors
patients presenting with an AIDS-defining illness.
Testing should also be considered in those with indicator disease (e.g pneumonia, oral candidiasis, Hodgkin’s lymphoma) and in areas of high–prevalence acute admissions and patients registering with a GP (Table 38.1).
| Risk assessment | Yes | No | Further information |
|---|---|---|---|
Prior HIV test | When | ||
Blood transfusion/products | When Where | ||
Injecting drug user (shared equipment) | Last time: | ||
Sex with people from countries with high HIV prevalence | Where:Last time: | ||
MSM or sex with MSM* | Last time: | ||
Contact with HIV Low risk Higher risk | Last time: | ||
Information provided | |||
Benefits of early identification and treatment explained Implication of positive result (especially if high risk) 3-month window explained Insurance explained Result giving explained | |||
Consent to test obtained | |||
HIV test taken | |||
Repeat test required | When: |
| Risk assessment | Yes | No | Further information |
|---|---|---|---|
Prior HIV test | When | ||
Blood transfusion/products | When Where | ||
Injecting drug user (shared equipment) | Last time: | ||
Sex with people from countries with high HIV prevalence | Where:Last time: | ||
MSM or sex with MSM* | Last time: | ||
Contact with HIV Low risk Higher risk | Last time: | ||
Information provided | |||
Benefits of early identification and treatment explained Implication of positive result (especially if high risk) 3-month window explained Insurance explained Result giving explained | |||
Consent to test obtained | |||
HIV test taken | |||
Repeat test required | When: |
MSM, ♂ who has sex with ♂.
HIV infection is usually diagnosed by detecting antibodies in a serum sample. Fourth generation testing should be standard and include p24 antigen with increased sensitivity and a false–positive rate of ~0.2%. However, in suspected 1° infections or 2–4 weeks after a specific high-risk incident (e.g. needlestick injury) plasma should be tested for HIV RNA by a nucleic acid amplification technique (e.g. PCR). Testing should always be done with informed consent and assurance about the confidential nature of the process. Point-of-care testing by fingerprick or mouth swab provides results within a few minutes and may be considered in community settings.
Pretest discussion should cover the following
Risk assessment: e.g. sexual practices, travel, drug use, occupation, blood/blood products prior to 1985 (in the UK).
Very high risk:
unprotected sexual contact with an HIV-infected partner
receipt of infected blood/blood products
sharing injecting equipment with HIV-infected person.
Assess patient knowledge: ensure that the individual understands the nature and transmission of HIV. Advise on risk reduction.
Standard antibody test—serum (saliva and finger-prick tests available if venepuncture impossible/refused):
Detects antibodies to HIV-1 and HIV-2, does not diagnose AIDS.
Seroconversion often within 4–6 weeks but may take up to 12 weeks ‘window period’; therefore repeat testing may be required. Repeat saliva testing advised 14 weeks after risk. Therefore it is important to determine the date of the last risk.
Positive standard screening tests need to be validated by different method(s) which may incur delays. Rarely indeterminate results are obtained, requiring repeat sampling.
If the patient lacks capacity they may only be tested if the test is in the patient’s best interest. The patient’s attorney may need to be contacted and any advanced directives must be considered. Discussion of reason for refusal should take place to ensure that it is not based on misconceptions.
Implications of testing
Early diagnosis allows monitoring with pre-symptomatic highly active antiretroviral therapy (HAART), if appropriate, and development of strategies to avoid transmission including post-exposure prophylaxis
If pregnant, allows informed choices about the management of pregnancy, especially the use of antiretroviral treatment (both mother and infant) and avoidance of breastfeeding to ↓ vertical transmission. Arrangements for early monitoring of the infant’s health.
If negative, elimination of needless anxiety and no consequence on life insurance or mortgage application.
If positive:
psychological impact of result
social and work implications (e.g. surgeon); may affect travel to or work in certain countries
life insurance restrictions/weightings; a positive result (or awaiting a test result) must be declared on application forms
Arrangements for giving results
How/when the result will be provided (especially in high-risk situations)
If positive, who will he/she tell? How will the individual cope? What support is available?
Document that information has been provided on:
positive, negative, and indeterminate results
how, when, and where results will be given and whether written confirmation is required
follow-up and the possible need for repeat testing to confirm positive results or cover the window period.
Obtain and document informed consent.
Post-test counselling
The content and timing of the discussion will depend on the patient’s reaction to a positive or negative result.
Aims of post-test counselling
Address the immediate concerns and provide support for those who are positive and also negative (especially the very anxious).
Provide information on the prevention of HIV transmission.
Ensure patient is aware of need for confirmatory/repeat testing if appropriate.
Discuss modifiable risk factors.
If HIV positive
Address immediate reactions and assess need for psychological intervention.
Provide further basic information about the natural history of HIV, reinforcing the difference between HIV and AIDS and the efficacy of treatment.
Construct a management plan which meets the needs of the patient.
Give details of support services.
Offer follow-up appointments and ongoing support which may include addressing issues concerned with employment, travel, legal matters, and support for carers and partners.
Discuss measures needed to prevent transmission and possibility of PEPSI for partners
Provide information on what further investigations will be required.
Negative HIV antibody test with HIV infection (after excluding specimen- handling errors) is well recognized during the window period. It is otherwise very rare and identified only when clinical presentation suggests HIV/AIDS with a negative HIV antibody test but positive PCR for HIV RNA/DNA (or viral culture). Possible causes:
profound hypogammaglobulinaemia
seroreversion—extremely rare
HIV group O infection
unknown.
Reticulo-endothelial abnormalities:
impaired immunity
unexplained lymphadenopathy
blood dyscrasia
Infections:
tuberculosis or atypical mycobacterial infection
Pneumocystis jiroveci (carinii) pneumonia
cerebral toxoplasmosis
oral or oesophageal candidiasis
herpes zoster (in younger people)
cytomegalovirus retinitis
aseptic meningitis
transverse myelitis
peripheral neuropathy
Tumours:
non-Hodgkin’s lymphoma/Hodgkin’s lymphoma
cerebral lymphoma
cervical cancer
lung cancer
head and neck cancer
anal cancer
Dermatological conditions
Seborrhoeic dermatitis
Recalcitrant psoriasis
General:
symptoms suggesting seroconversion illness, especially if associated with another STI
oral hairy leukoplakia
unexplained weight loss
unexplained diarrhoea
night sweats
pyrexia of unknown origin
Assessment of an HIV-positive patient
Initial assessment
Objectives
Reinforce the patient’s understanding of HIV infection and how to avoid further transmission.
Identify medical, socio-economic, and legal problems.
Establish stage of disease.
Establish a rapport with patient (essential to ensure efficient follow-up).
Full history, medical examination, and baseline investigations to plan future management and drug therapy. Further tests depend on the circumstances and stage of disease.
History
Sexual history including sexual partners/practices, condom use, and contraception.
Current and previous medical history (especially tuberculosis, STIs, or hepatitis) and surgical, gynaecological, and obstetric history.
Extensive systemic enquiry covering GI, neurological, visual, respiratory, and cardiovascular systems.
Current medication and allergies.
Drug, substance, and alcohol use.
Clinical examination
General: weight, temperature, pulse, blood pressure, respiratory rate, pallor, and jaundice.
Lymph glands: lymphadenopathy—site, size, symmetry, tenderness, and consistency.
Mouth and throat: gum and tooth disease, oral ulceration, hairy leukoplakia, candidiasis, and enlarged pharyngeal lymphoid tissue.
Cardiovascular: routine examination.
Respiratory: routine examination.
Abdomen: routine examination.
Neurological: routine examination. Specifically assess eyes, checking visual acuity, visual fields, pupil size, pupil reactivity, and extra-ocular movements. Examine retinae, ideally with pupils dilated; if CD4 <50cells/μL slit-lamp examination by ophthalmology.
Genital/pelvic examination: discharges, ulcers, condylomata, testicular enlargement or atrophy, cervical abnormalities, pelvic masses, and STI screening.
Cervical cytology: annual review with close follow-up if abnormal.
Perianal and rectal examination: anal/rectal discharge, condylomata, ulcers, prostate assessment, and tests for STIs as appropriate.
Skin: general skin examination specifically checking for seborrhoeic dermatitis, fungal nail infection, warts, Kaposi’s sarcoma, molluscum contagiosum, and abnormal pigmentation.
Laboratory investigations
Full blood count, urea, electrolytes and liver function tests, glucose, triglycerides, and cholesterol.
Serological tests: hepatitis A, hepatitis B (surface antigen and core antibody), hepatitis C, CMV IgG, toxoplasma, varicella zoster virus (VZV) IgG, and syphilis.
Viral load (VL)—informs on likely rate of disease progression and monitors response to therapy:
undetectable VL indicates level <20–50copies/mL (depending upon test used)
<5000copies/mL generally suggests low rate of progression in the coming 5 years
>55,000copies/mL is associated with ↑ rate of progression.
CD4 count—usually measured as part of lymphocyte subsets:
main indicator of risk of opportunistic infection and possible need for prophylactic treatment in the asymptomatic patient
individual results may be influenced by other factors, e.g. inter-current infections
repeat if unexpectedly low or high count.
trend is more useful than single readings.
Plasma samples for viral resistance testing.
When you are diagnosed you will speak to a health adviser who will discuss this and similar issues with you. You should be careful who you tell, as once it’s done, there’s no going back. Although safety precautions are taken, you should inform anyone who could come into contact with infected body fluids (e.g. dentists, surgeons) and your doctor, especially if you develop unusual symptoms which may be related to or altered by the HIV infection. If you are a healthcare professional (HCP) you should seek appropriate counselling, as certain invasive procedures cannot be performed by HIV-positive HCPs.
It is important to act responsibly where others are concerned, especially sexual (or drug-sharing) partners. There are court cases where HIV-positive individuals have been prosecuted for infecting partners without informing them that they are HIV positive.
Further investigations and follow-up
Chest X-ray.
Estimate stage of HIV infection from initial assessment and baseline investigations.
Assess disease progression: HIV-related infections and malignancies, response to therapy, and signs of drug toxicity.
Monitor VL and CD4 count at regular intervals; frequency depends on the patient’s clinical status. Asymptomatic patients with stable disease may have their VL and CD4 count measured every 3–6 months but shorter intervals may be necessary for those with more advanced disease.
Drug prophylaxis
Pneumocystis jiroveci (carinii) pneumonia (PCP): when CD4 count <200cells/μL, first choice is trimethoprim/sulfamethoxazole (co-trimoxazole) orally 960mg 3 times a week. If allergic consider desensitization (Table 38.2). Alternatives are: dapsone 50–100mg daily, dapsone 50mg plus pyrimethamine 50mg 3 times a week, atovaquone 750mg 3 times a week, or nebulized pentamidine 300mg once a month. Azithromycin 500mg 3 times a week may be effective as 1° prophylaxis.
Tuberculosis (TB): prior BCG vaccination provides unreliable protection. A negative tuberculin test may be due to anergy and does not exclude TB. Chemoprophylaxis is recommended for close contacts of smear-positive pulmonary TB. Six months of isoniazid 300mg daily or 3 months of isoniazid 300mg daily plus rifampicin 600mg daily is effective.
Toxoplasmosis: if CD4 count <100cells/μL and toxoplasma IgG positive. Co-trimoxazole (as for PCP prophylaxis).
VZV: varicella zoster immunoglobulin (5 vials IM) if seronegative for VZV antibodies within 72 hours of significant exposure.
| Day | Dose | TS |
|---|---|---|
1 | 1mL of 1:20 paediatric suspension | 0.4mg/2mg |
2 | 2mL of 1:20 paediatric suspension | 0.8mg/4mg |
3 | 4mL of 1:20 paediatric suspension | 1.6mg/8mg |
4 | 8mL of 1:20 paediatric suspension | 3.2mg/16mg |
5 | 1mL of paediatric suspension | 8mg/40mg |
6 | 2mL of paediatric suspension | 16mg/80mg |
7 | 4mL of paediatric suspension | 32mg/160mg |
8 | 8mL of paediatric suspension | 64mg/320mg |
9 | 1 tablet | 80mg/400mg |
10 | 1 double-strength tablet | 160mg/800mg |
Thereafter 1 double strength tablet 3 days a week until CD4 count is >200cells/μL for at least 3 months. | ||
| Day | Dose | TS |
|---|---|---|
1 | 1mL of 1:20 paediatric suspension | 0.4mg/2mg |
2 | 2mL of 1:20 paediatric suspension | 0.8mg/4mg |
3 | 4mL of 1:20 paediatric suspension | 1.6mg/8mg |
4 | 8mL of 1:20 paediatric suspension | 3.2mg/16mg |
5 | 1mL of paediatric suspension | 8mg/40mg |
6 | 2mL of paediatric suspension | 16mg/80mg |
7 | 4mL of paediatric suspension | 32mg/160mg |
8 | 8mL of paediatric suspension | 64mg/320mg |
9 | 1 tablet | 80mg/400mg |
10 | 1 double-strength tablet | 160mg/800mg |
Thereafter 1 double strength tablet 3 days a week until CD4 count is >200cells/μL for at least 3 months. | ||
Reprinted from Absar, N. Daneshvar, H., Beall, G. (1994). J Allergy Clin Immunol, 93, 1001–5. © 1994 with permission from Elsevier.
Vaccination
Inactivated rather than live vaccines should be used (e.g. polio). If
travelling abroad additional vaccination may be required (
Chapter 55, Vaccination p. 612). Those who are immunodeficient may not mount a
good response to vaccination. Vaccination can be delayed until immune
reconstitution ensues, although unnecessary delay should be avoided if
there is a specific infection risk.
Influenza vaccination: can be given to all patients.
Hepatitis A: if immuno-naive.
Hepatitis B: if immuno-naive.
Pneumovax: controversial, but safer if given to those whose HIV infection is suppressed by antiviral therapy with CD4 >200cells/μL.
