Late HIV Diagnosis Warning

posted: 23/04/2010

Far too many people in the UK with HIV are being diagnosed late, when they may have had the virus for as long as 10 years and are likely to have passed the infection to other people, sexual health experts warned. In Manchester, the British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH) conference is under way.
 

Urgent action is needed to make routine testing the norm in areas where HIV prevalence is high – and this includes Manchester, Salford and Blackpool in NW England. HIV rates in the UK are steadily rising, and delays in diagnosing infection increase deaths and onward transmission.

NW is late diagnosis hotspot

NW England has the worst rate of late diagnosis of all regions in England. Manchester last year had the largest number diagnosed late, 54 out of 142 people: 38% diagnosed late. But this is next door to Manchester's twin city Salford, where just 23.9% were late (11 out of 46). The national average rate for late diagnosis is a high 32%.

"It is in the interest of everyone for local health authorities and healthcare professionals to take a real stance on this issue," said Dr Keith Radcliffe, president of the British Association for Sexual Health and HIV.
 

1 in 3 diagnosed late
The conference heard that more than a third of HIV infections were still being diagnosed late. If infection is missed at an early stage there may be no symptoms for 10 years, until the patient falls seriously ill with a potentially fatal AIDS-related condition.
 

There is a window of opportunity to diagnose HIV early, during what is known as sero-conversion, when the body produces antibodies to the virus. It is also the time when people with HIV are the most infectious. The person is likely to have a flu-like illness including a rash and a sore throat.
 

Missed chances
But Dr Mark Pakianathan, a London-based HIV consultant, said GPs and A&E staff may not realise it could be HIV – or may not want to suggest a test.
 

Sometimes doctors are reluctant to raise the possibility because of their own assumptions about the person’s lifestyle. "They think it can't be HIV – it must be something else," said Pakianathan. The doctor may assume it is glandular fever or even swine flu. "An opportunity could be lost for 10 years," he added.
 

Later clues
There can be an intermediate phase, when patients may be diagnosed with illnesses such as fungal nail infection, related to the erosion of their immune system by the virus. But often patients are not diagnosed until they develop an AIDS-related illness such as a lymphoma or bacterial meningitis, which can be life threatening.
 

More than 7,000 new HIV diagnoses are made every year in England, Wales and Northern Ireland. At the end of 2008 there were an estimated 83,000 people infected, according to the Health Protection Agency.
 

Testing is a lottery
Studies presented at the conference showed what Radcliffe called the "lottery" in HIV testing. An investigation of HIV testing patterns in a large inner city hospital with high local prevalence found that 41% of HIV-positive patients had been in contact with a health professional, with a HIV-related symptom, in the last two years but had not been offered a HIV test.
 

A second study, lasting six months, of acute general medical admissions, found that only one third of undiagnosed HIV-positive patients were correctly advised to have a HIV test by clinicians. The two-thirds who were missed would have been identified if HIV testing was made routine for all general hospital admissions.
 

Testing urged because of treatment successes
Pakianathan said some clinicians seemed not to have caught up with the massive change in the prospects for people with HIV that has come about in the last decade with the availability of drugs that can keep people not only alive but well and active for the foreseeable future. He had visited GP surgeries in London to talk to them about de-stigmatising HIV testing.
 

"I still get [doctors and nurses] saying: 'When I offered a test, the patient got up and left the room'. It is about how  you offer the test as well," he said.
 

Professor Ian Gilmore, president of the Royal College of Physicians, said: "Someone in their early 20s promptly diagnosed with HIV can today, with the current treatments available, look forward to a relatively normal life, whereas delayed diagnosis and treatment increase the rate of illness, premature death and the unknowing spread of the disease. Changing patterns of HIV transmission further underscore the need to raise awareness among physicians and make the test a standard first-line investigation in many secondary care settings."
 

BHIVA HIV Testing Guidelines

Source
 

Treat Gay Swiss at Diagnosis?

posted: 19/04/2010

Swiss researchers are now suggesting that all HIV positive gay / bi men should be offered HIV treatment straight after diagnosis, to control the Swiss HIV epidemic among gay and bi men. They found that most new HIV infections amongst gay men in Switzerland came from men who have had HIV for some time, and all of these men had stopped taking treatments. In this Swiss study, HIV rarely came from newly infected men.

Treat to prevent
The investigators believe that their findings support “early” and “continuous” use of HIV treatment by gay men, and suggest that this could profoundly slow the HIV epidemic in this population.

We think the Swiss should concentrate instead on finding out why these men have stopped taking treatments and are having unprotected sex, and deal with those.

Treating everyone at diagnosis would help cut the numbers of new infections, but men with HIV have every right to choose whether to take anti-HIV treatment. No one has the right to force HIV treatment on people, even if this will help reduce the number of people getting HIV.

The UK national treatment guidelines advise people to start HIV treatment when it is best for that individual with HIV, not as a normal means of HIV prevention to protect others.

Infection clusters
An in-depth knowledge of the dynamics of HIV transmission among gay men helps us plan effective prevention campaigns. Swiss investigators (using the Zurich Primary Infection study and the Swiss HIV Cohort study) used phylogenetic analysis to discover clusters of closely related-HIV transmissions among recently infected gay men.

Stopped treatment
They mapped the clusters of HIV transmissions amongst gay men recently infected with HIV. They found only two men whose HIV came from men who had only just got HIV themselves. Almost every Swiss man’s infection came from a guy who had HIV for at least one year, and it was always from a man who had stopped taking HIV treatment. “Infectiousness during chronic infection was quite high in this population”, comment the investigators.

They found identified six transmission clusters involving 20 men from the Zurich cohort and eight individuals from the wider Swiss cohort. Only two infections appeared to originate in individuals with very recent HIV infection. The rest had their source in chronically-infected individuals who had stopped taking HIV treatments. These men had viral loads ranging from 314 – 1,690,000 copies/ml.

The investigator’s first analysis suggested that one man who was taking HIV therapy and had an undetectable viral load may have transmitted HIV to his partner. However, further genetic analysis found three other patients with more closely matched virus – one of whom was the source of the HIV.

“We detected a remarkable proportion of new infections originating from … patients …. already in their chronic phase”, comment the investigators. They add, “These findings argue strongly for early, continuous antiretroviral therapy in sexually active HIV-infected men who have sex with men. This strategy, most likely, will have a profound impact to reduce further spread of HIV.”

George House Trust comment

The Swiss authors don't explain how treating every gay / bi man with HIV will work when almost all Swiss the infections in this study come from men who have chosen to stop taking their treatment. It is wrong to force treatment on people.

We think it makes far more sense for the Swiss to understand why these men

• stopped taking all HIV treatment
• are having unprotected sex

and then to provide better treatment and prevention support.

Local solutions for each local epidemic

Treating every gay and bi man with HIV might just be the solution for the gay / bi HIV epidemic in Switzerland, but it is not likely to be the best solution for England. For example in England we know that a significant proportion of new gay / bi HIV infections come from men who were just infected themselves.

Source with reference

Tell Your Living Story

posted: 01/03/2010

Terrence Higgins Trust is looking for gay men with HIV to share their stories online on their What Next? website for gay men recently diagnosed HIV positive.

The What Next? website  is looking for gay men to keep an online diary, whether you’ve been diagnosed recently or living with HIV for longer. Part of the website includes videos and diaries describing men’s personal experience. Want to share yours?

What they are looking for is the story of what you’re up to and how you’re getting on in about 500 words, once a month, and they will then post this on the What Next? website for you. You will need to agree to have your photograph on the site.

If sharing your experiences online interests you, or you would like more information, please feel free to contact Stephen Adair at Terrence Higgins Trust or call him on 020 7812 1783.
 

Late Diagnosis in Parliament

posted: 05/02/2010

Watch a BBC video of a parliamentary debate about the late diagnosis of HIV in Westminster Hall held on Wednesday, which was led by David Borrow MP.

More than half the people diagnosed with HIV in the UK are being diagnosed late - seriously reducing their health and life expectancy.

NW England – the late diagnosis hotspot
The late diagnosis rate varies dramatically between PCTs in England, but NW England has the countries highest rate of late diagnosis. The figures can be distorted when the numbers diagnosed in some PCTs are very small, and North Lancashire has twice the national average rate (62% were late diagnosed), but the numbers diagnosed here are low.

Far more worrying is Manchester, because it has by far the largest number diagnosed every year in the region and last year it had the largest number daignosed late in the region last year, 54 out of 142 people: 38% diagnosed late. But this is next door to Manchester's twin city Salford, where just 23.9% were late (11 out of 46). It is difficult to understand how living on one side or the other of the River Irwell can make such a difference.

In the debate, Mr Borrow, who chairs the All Party Parliamentary Group on AIDS, also said many people with HIV were reluctant to inform their GP because of the stigma attached to the condition.

He said testing should become more routine, and that HIV awareness should be incorporated into medical training.

Health Minister Gillian Merron said the government was working to "normalise" HIV testing by making it more accessible through GPs and hospitals, and not just specialist sexual health clinics.

Late diagnosis to get earlier

Earlier this week we reported that the goalposts for late diagnosis are about to be moved so they are earlier. At present the definition for late diagnosis is when HIV is diagnosed when the CD4 count is 200 or below. It is now recommended that the late diagnosis threshold should be raised to a CD4 of 350 (by which point HIV treatment should normally be started), because it is clear that people's health and life prospects are worsened when treatment starts later than this.

Watch the video of the debate

Image source Photograph by Deryc Sands - parliamentary copyright - reproduced with the permission of Parliament

Late diagnosis report from Health Protection Agency, November 2009

Late Diagnosis Gets Earlier

posted: 29/01/2010

Late HIV diagnosis will be sooner after infection, and a new stage of HIV infection, ‘advanced HIV disease’ is proposed for the UK.

‘Late diagnosis’ is fuzzy and confusing – it means different things depending on who you talk to. The boundary line of when diagnosis is late has also been shifting over time. UK experts are now saying we need to end the confusion and bring things up to date so we all talk about and mean the same thing. They looked at thousands of people diagnosed in the UK, their CD4 counts and what became of them.

Late diagnosis matters. Many people are diagnosed late and starting treatment late means you don’t get the full benefit of HIV treatment. People diagnosed late are more likely to get HIV illnesses and die sooner than people who start treatment at the best time. And people diagnoses late are more infectious and therefore more likely to pass on HIV without realising this.

The 'new late' : any CD4 below 350
A CD4 count of 350 is when most people in the UK should start treatment. The UK researchers now say that anyone diagnosed with HIV with a CD4 count below this 350 has a late diagnosis. In the USA, guidelines for treatment now say treatment should start when the CD4 count is between 500 and 350. It is likely that the UK treatment guidelines will soon say something similar. The benefits of starting treatment sooner are becoming clear.

‘Advanced HIV disease’
A new HIV disease stage is also proposed for the UK. If a person at diagnosis has any of the things that are associated with a higher risk of death within three months – such as a CD4 cell count below 200 or an AIDS-defining illness – they should be described as having ‘advanced HIV disease’.

Late diagnosis is a blight
Large numbers of people diagnosed in Europe and elsewhere are diagnosed late. Most of the HIV-related deaths in Europe are among people who were diagnosed late.

Diagnosing more people earlier would help cut the amount of HIV-related illness and death. Cutting late diagnosis would also reduce the spread of HIV - people who are diagnosed late have high viral loads and are more infectious.

What’s late?
Investigators from the UK Collaborative HIV Cohort (UK CHIC) looked at information on 15,774 people seen between 1996 and 2006 to find “a definition that can reliably identify a high proportion of individuals who will die shortly after their HIV diagnosis”.

Overall, 10% of people had a CD4 cell count below 50 cells/mm3 at the time of diagnosis, and another 17% had a CD4 cell count below 200 at diagnosis. But for 14% of the people in the study no CD4 figures at the time of diagnosis were available.

Just under 10% of people had an AIDS-defining illness at the time of their HIV diagnosis. For 2.4% of people this illness was moderate or severe and posed a significant risk of death.

Almost 4 out of 5 people with a CD4 cell count below 50 also had an AIDS-defining illness at diagnosis. Almost half the people with a more serious AIDS-defining illness had a CD4 below 200, but 4 out of 5 people who had a serious AIDS-defining illness at diagnosis had a CD4 count below 50.

206 (1.3%) people in the study died within three months of their HIV diagnosis.

More deaths with lower CD4, advanced illness signs 

The death rates were highest for all the disease stages the researchers now propose.

If your CD4 cell count is below 200 at diagnosis the mortality rate within three months is 3%. If the CD4 count at diagnosis is below 5o, the mortality rate after three months reaches 5%.

If you have an AIDS-defining condition when HIV is diagnosed then there is a 6% chance of death within the next three months. If you have a potentially life-threatening AIDS-defining condition at diagnosis then the risk of death rises to 10% within three months.

But a lot of useful data is missing – for 45% of the people who died there was no CD4 count.

Combining CD4 cell counts and clinical characteristics proved a more reliable guide than just looking at CD4 counts, or just looking at clinical stages of HIV illness. Using both together accounted for over two-thirds of the people in the study who died.

Late and advanced disease recommendations
“We propose that any individual who presents with either a CD4 cell count below 200 cells/mm3 or a clinical AIDS event is defined as presenting with advanced HIV disease”, write the investigators.

In addition they suggest that patients diagnosed with a CD4 cell count below 350 cells/mm3, or who develop an AIDS-defining illness within a month of diagnosis should be classified as having their HIV diagnosed late.

The investigators caution that a reliance on CD4 cell counts alone would not identify a substantial number of patients who have advanced HIV disease and a high risk of death at the time of their diagnosis. They write, “these patients may present and die without having their CD4 cell count measured”.

They hope that their proposed definitions will facilitate cross-country comparisons and help identify patients with a high risk of advanced disease at the time of their HIV diagnosis.

Source and Journal reference