BHIVA/BASHH/BIA adult HIV testing 2020 Flashcards
What are the 3 key benefits of early initiation ART?
for patient - reduce morbidity and mortality
for partner - reduce risk of transmission
for public - reduce community HIV transmission
What proportion of people living with HIV remain undiagnosed?
7%
What proportion of people living with HIV present with a late diagnosis?
43%
What is the problem with late diagnosis presentation of HIV?
Higher risk of morbidity and mortality both short and long term
Those who are HIV negative but at risk of HIV what 3 public health measures should be offered?
Condoms
Regular testing
Health promotion around safe sex/harm reduction
PrEP
What is the window period for 4th generation serological HIV testing?
45 days
In 2018, what proportion of people were -
diagnosed with HIV,
on ART and
with a undetectable viral load?
93% DIAGNOSED
97% on ART
97% undetectable VL
Which high risk group has had the most marked reduction in HIV new diagnoses?
MSM in London
What are the most likely reasons for the reduction in incidence of HIV?
Increased testing
Repeat testing
Treatment as prevention (TasP)
PrEP
At what prevalence of undiagnosed HIV is it cost effective to provide HIV screening?
0.1%
What is the undiagnosed prevalence in England?
0.016%
Is it considered cost effective to provide HIV screening across England?
NO
Prevalence 0.016%, for cost effectiveness needs to be 0.1%
At what prevalence of undiagnosed HIV in pregnant women is it cost effective to provide HIV screening?
0.0075%
lower than the general population threshold due to larger costs associate with infant acquired HIV
List the groups of people with increased risk of HIV? [hint: there are 10 and 1 bonus]
SEXUAL RISK (5): MSM Female sex partners of MSM Sex workers Transwomen Sex with a person from high diagnosed seroprevalence (>1%) GEOGRAPHIC RISK (2): Black Africans Person from country with high diagnosed seroprevalence (>1%) SOCIAL RISK (3): PWID (past or current) Prisoners (past or current) Mother with HIV and no documented negative status
Bonus:
Transmen
What percentage is consider a high DIAGNOSED seroprevalance?
> 1%
In which FIVE healthcare settings should HIV testing be opt-testing as routine?
SRH: Sexual health services Antenatal services Termination of pregnancy services BBV: Addiction and substance misuse services CONDITIONS WITH INCREASED RISK OF HIV: Healthcare services for Hepatitis B or C, TB or Lymphoma
There are 5 healthcare settings in which HIV testing should be routine. In what other clinical settings should patients be offered HIV testing?
Individuals starting:
Chemotherapy, immunosuppressive or immunomodulatory therapy
(as per NICE)
What are the FIVE broad groups of people who should be offered HIV testing?
1) People in high risk groups
2) People attending certain healthcare settings
3) People with symptoms or signs of an HIV indicator condition
4) People accessing healthcare in areas of HIGH or EXTREMELY HIGH HIV seroprevalence (regardless of reason for attendance)
5) Sexual partners of those diagnosed with HIV
What is the the definition of high and extremely high prevalence of HIV?
HIGH - 2-5 per 1000
EXTREMELY high - >5 per 1000
What is the estimated undiagnosed
prevalence of HIV in the UK for MSM?
0.681% (6-7 per 1000)
What is the estimated undiagnosed
prevalence of HIV in LONDON for MSM?
0.714%
What is the estimated undiagnosed
prevalence of HIV in the UK for Black African people?
0.165% (1-2 per 1000)
Is the estimated undiagnosed
prevalence of HIV in the UK higher for Black African MEN or WOMEN?
WOMEN
0.189% vs 0.136% for men
What is the estimated undiagnosed
prevalence of HIV in the UK for PWID?
0.089% (approx 1 per 1000)
What is the rate of uptake of HIV screening among women attending for antenatal care?
> 99%
very high
What is the percentage of positive HIV tests among women attending for antenatal care?
0.013%
ie > 0.0075% the cost effectiveness threshold
From which countries are TWO studies used to support HIV testing in antenatal care?
Australia
USA
What did Public Health England use to model HIV prevalence distribution?
k-median cluster analysis
What proportion of late HIV diagnoses were identified to occur in areas of high or extremely high prevalence of HIV?
TWO THIRDS (2/3)
What is the aim of ‘geographical targeted testing’?
To REDUCE the number of individuals living with HIV who are UNAWARE
of their infection in geographical areas where UNDIAGNOSED PREVALENCE is high (>1 PER 1000)
What is the benefit of ‘geographical targeted testing’?
Overcomes the need to target HIV testing to any specific population,
potentially PREVENTING further STIGMATISATION of these populations
In what scenarios, should repeat HIV testing be done? [hint: there are 4]
1) If testing done within window period from last risk
2) ongoing high risk behaviour
3) Follow up testing for other STIs
4) PrEP monitoring
Which THREE groups of people should have annual HIV testing at a MINIMUM?
PWID
Sex workers
MSM
When should MSM be offered 3 monthly HIV testing?
1) condomless anal sex last 12 months
2) multiple or anonymous sexual partners
3) more than 10 sexual partners last 12 months
4) Drug use during sex last 6 months
Drug use during sex is an independent risk factor for HIV transmission, HIV testing should be offered if this has occurred over what time period?
Drug use in last
SIX (6) MONTHS
What strategies can be used to increase repeat HIV testing in groups? [hint: name 3]
1) Recall of people eligible for PrEP but declined
2) Text reminders
3) Home sampling kits
There is limited data for repeat HIV testing in groups outwith MSM. What was the rate of HIV positivity in heterosexual population in LONDON?
1 out of 4584 (repeat testing within 12 months)
Retrospective review 31 469, heterosexual, diverse ethnicity. 4584 retested within 12 months - 1 HIV positive.
At what prevalence of HIV is it cost effective to offer HIV testing annually for heterosexual populations?
0.8% prevalence
During 3 month follow up of MSM diagnosed with bacterial STI in London, what proportion had a new STI and what proportion had HIV?
New STI - 29 out of 301
HIV - 5 out of 301
(301 MSM diagnosed with bacterial STI, 206 re-attended 6 months - 29 new STI and 5 HIV positive)
What is the benefit for HIV testing using a mixed model (clinic-based+home-based) vs clinic only?
INCREASE in HIV positive INCIDENCE
4.2 vs 1.9 per year (Australia)
What are THREE potential barriers to accessing health care based HIV testing?
1) inconvenience
2) confidentiality concerns
3) fear of stigma
What THREE HIV testing systems offer alternatives to testing within sexual health services?
1) HIV self-testing (test + interpret at home)
2) self-sampling (collect sample + send to lab)
3) outreach community testing
What is the term used to describe a self-sampling HIV test that shows a positive result?
REACTIVE
there is a small possibility of a false positive
In Europe, what is the sensitivity and specificity of all approved blood-based self-test HIV testing kits?
> 99%
In Europe, what is the assay used for all approved blood-based self-test HIV testing kits?
2nd or 3rd generation assay
mostly 3rd in UK
If a persons self-test for HIV is reactive, what must be performed next?
A confirmatory laboratory test
there is a small possibility of a false positive
HIV self-testing is highly acceptable, what benefits do patients cite?
1) ease
2) convenience
3) privacy
4) immediacy
5) anonymity
6) no need to visit healthcare centre
What barriers are reported by patients to using HIV self-tests?
1) cost
2) fear of carrying out blood test
3) interpreting outcome
4) having a reactive result without support
What is the potential positive impact of using oral fluid self-tests for HIV testing?
TWO fold increase in testing UPTAKE
HIV test window period should be based on 99th percentile estimates, what is the window period for 4th generation laboratory tests?
FOURTY FIVE (45) days
HIV test window period should be based on 99th percentile estimates, what is the window period for 3rd generation laboratory tests?
SIXTY (60) days
HIV test window period should be based on 99th percentile estimates, what is the window period for point of care tests?
NINETY (90) days
When should molecular assay for viral RNA or proviral DNA be used as part of the screening or confirmatory test?
1) Primary HIV infection
2) Indeterminate serology on PrEP
Diagnosing breakthrough HIV infections on PrEP can be challenging. What THREE tests might be used?
1) ANTIGEN/ANTIBODY 4th generation
2) RNA and proviral DNA MOLECULAR ASSAY
3) WESTERN BLOT
How should you manage/follow up atypical or non-confirmatory HIV tests on PrEP?
Stop PrEP
Repeat HIV test at 4 weeks and 8 weeks
What THREE situations might blunt the HIV antibody response and therefore result in an atypical HIV serology?
1) PEP
2) PrEP
3) early ART initiation
BARRIERS to HIV testing, STRUCTURAL/ORGANISTATIONAL level - what are they?
1) ACCESS to service
- geographical distance, opening times, length of waiting time, time for test result
2) testing ENVIRONMENT
3) service CAPACITY
- insufficient time, training gaps
4) COST
BARRIERS to HIV testing, HEALTHCARE PROFESSIONAL level - what are they?
LACK of
1) KNOWLEDGE and SKILLS who to test
2) relevant COMMUNICATION skills
3) POCT skills
BARRIERS to HIV testing, INDIVIDUAL level - what are they?
1) Lack of AWARENESS for need to test
2) FEAR of positive result or HIV illness
3) Lack of KNOWLEDGE of benefit of treatment
What symptoms or signs should prompt HIV testing?
Mononucleosis-like illness Fever Lymphadenopathy UNEXPLAINED - weight loss - diarrhoea - fever - oral candidiasis
What aspects to a routine blood panel that might be abnormal should prompt HIV testing?
leucocytopenia
thrombocytopenia
chronic renal impairment
What VIRAL infections should prompt HIV testing?
HZV HSV CMV Hepatitis A, B, C JC virus (PML)
What NEOPLASIA should prompt HIV testing?
Cervical dysplasia/cancer Anal dysplasia/cancer Malignant lymphoma Primary lung cancer Kaposi’s sarcoma
What BACTERIAL infections should prompt HIV testing?
Community acquired pneumonia TB MAC Salmonella septicaemia (recurrent) STI Invasive pneumococcal disease
What PARASITIC infections should prompt HIV testing?
Cerebral toxoplasmosis
Cryptosporidiosis diarrhoea
Cystoisosporiasis (isosporiasis)
Visceral leishmaniasis
What FUNGAL infections should prompt HIV testing?
PCP Candidiasis (oral, GI, respiratory, blood) Crytococcus Histoplasmosis Coccidioidomycosis Talaromycosis
What DERMATOLOGICAL presentations should prompt HIV testing?
Seborrhoeic dermatitis
Psoriasis (severe or atypical)
Oral hairy leukoplakia
What NEUROLOGICAL presentations should prompt HIV testing?
Mononeuritis
Peripheral neuropathy
Multiple sclerosis-like disease
Guillain-Barre syndrome
