HIV – A test in time saves lives

Historically…
Approximately three decades ago in the New York Times, there was a report of an outbreak of a rare form of cancer – Kaposi’s Sarcoma (KS) among gay men in New York. Prior to this time, KS had only been described in older people and was a relatively benign cancer. However by March 1981, at least eight cases of a more aggressive form of KS had been reported amongst young gay men in New York. About the same time, there was an increase in the number of cases of a rare lung infection Pneumocystis carinii pneumonia (PCP) also in gay men in both new York and California.¹

A ‘cellular-immune dysfunction related to a common exposure’ was thought to be the underlying problem in these young gay men.

In the UK, a similar case was identified – a young man with haemophilia, followed by further reports among homosexual men.

These were the first reported cases of Acquired Immune Deficiency Syndrome (AIDS) – a name given to this condition in 1982. A virus was identified as the cause of AIDS in 1984 and by the end of that year, 7,699 AIDS cases and 3,665 AIDS deaths had been recorded in the USA, 762 cases had been reported in Europe and in the UK there had been 108 cases and 46 deaths.

The first test for the virus was approved in 1985 and in October of that year it became mandatory to test all blood donations in the UK routinely for it. In the same year, it was reported that the virus had been transmitted from mother to child.

In 1986, HIV (Human Immunodeficiency Virus) was accepted as the name for this virus causing AIDS. In the same year, Zidovudine (AZT) – a drug which had failed as a possible anticancer drug when first synthesised in 1964 was found to slow down the attack of HIV on the immune system.

Where are we today?
The World Health Organisation (WHO) estimates that by the end of 2009 about 33.3 million people were living with HIV.² Of these, 30.8 million are adults and about half of these are women (15.9 million).

In 2009, 2.6 million people were newly infected with the virus and approximately 1.8 million deaths occurred as a result of AIDS. Looking at figures for the same year in the UK, the Health Protection Agency (HPA) reports that about 86,500 people were living with HIV. What is however more worrying is that approximately a quarter of these people are unaware of their infection – so this means over 20,000 people living in the UK are oblivious of the fact that they are HIV positive.

6,630 people were newly diagnosed in 2009 in the UK and half of the adults diagnosed with HIV were at a late stage of infection (CD4 counts less than 350 per mm3 within three months of diagnosis) – the stage at which treatment is recommended to begin. A study in Black-Africans showed that in the year leading up to the diagnosis of HIV in 263 people, of whom 49.8% presented with advanced disease, 76% saw their GP, 38% had been seen in an outpatient service and 15% had been inpatients.³

It is estimated that the number of people living with HIV in the UK (diagnosed and undiagnosed) will reach 100,000 by 2012.⁴

Figures from the Health Protection Agency (HPA) show that new diagnoses for people infected with HIV in the UK almost doubled over the past decade (from 1,950 in 2001 to 3,780 in 2010). If these 3,780 UK-acquired HIV cases in 2010 had been prevented, over £32 million annually or £1.2 billion over a lifetime in costs would have been saved.

The prevention of one new HIV infection is said to save the public purse between £280,000 and £360,000 in direct lifetime healthcare costs.⁵

Figure 1. Annual new HIV diagnoses by prevention group: UK, 1981-2010.

What has changed?
Highly Active Anti Retroviral Therapy (HAART) has changed the horizon of HIV management. Over 20 drugs are now available to choose from and treatment is given as a combination of at least three drugs. Antiretroviral treatment suppresses viral replication therefore allowing reconstitution of the immune system. This has resulted in significant improvement in life expectancy.

Universal HIV testing – what about it?
This basically means that all individuals attending a specified setting are offered and

recommended a HIV test as part of their routine care but an individual has the option to refuse testing. This has been the practice in all NHS antenatal services since 2000 and all GUM clinics in the UK since 2006.

In antenatal clinics for example, adopting this practice has led to an increase in the uptake of HIV testing which is now about 95%.⁶ Consequently, there has been a significant reduction in the proportion of HIV infections that remain undiagnosed prior to delivery, from 18% in 2000 to fewer than 10% in 2006.⁷ This has promoted the early diagnosis of HIV in HIV positive pregnant women. The subsequent availability of prophylactic treatment in conjunction with avoidance of breastfeeding has resulted in a significant reduction of mother to child transmission.

Most recent figures show that less than 2000 children in the UK have been diagnosed with HIV as a result of mother to child transmission. Nearly half of these children were actually infected abroad.

Benefits of testing
Early testing results in early diagnosis and treatment which would therefore reduce the chances of progressing to AIDS, improve quality of life and prolong life.

Late diagnosis of HIV infection is associated with:

• Increased mortality and morbidity⁷
• Impaired response to HAART⁸
• Increased cost to healthcare services⁹

From a public health perspective, knowledge of HIV status is associated with a reduction in risk behaviour¹⁰ and therefore it is anticipated that earlier diagnosis will result in reduced onward transmission.¹¹

Barriers to testing
Some of the barriers to testing identified by Burns et al are – clinician’s perception of the patient’s risk, prejudice (both on a personal and institutional level) and time constraints of staff.¹² Also, some healthcare workers consider themselves ‘incompetent’ to offer HIV testing.

Who can test?
According to the UK national guidelines for HIV testing 2008, ‘It should be within the competence of any doctor, midwife, nurse or trained healthcare worker to obtain consent for and conduct an HIV test’.

Lengthy pre-test HIV counselling is no longer required. A pre-test discussion would suffice and during this discussion one should:

• Obtain informed consent for the test
• Discuss the benefits of testing with the individual
• Let the individual know how they would obtain their result

This has been the approach used in antenatal and Genitourinary clinics in the UK. It is generally acceptable and has been hugely successful.

In summary
HIV continues to be one of the most important communicable diseases in the UK. Though not yet curable it is no longer a death sentence but a chronic treatable condition.

With successful treatment these days, life expectancy is close to normal. However the benefits of treatment rely on early diagnosis. Late diagnosis is associated with poorer prognosis and higher costs. Early testing means early diagnosis.

References

1. CDC. Pneumocystis pneumonia – Los Angeles. MMWR 1981;30:250-2
2. WHO Global summary of the HIV/AIDS epidemic, December 2009
3. Burns FM et al. Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS 2008; 22:115-122.
4. Health protection report Volume 5 No 22
5. Health Protection Agency. HIV in the UK: 2009 Report. http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/0911HIVUK2009Report. Publication date November 2009
6. Health protection report Volume 4 No 47
7. Health Protection Agency (HPA), Centre for Infections. The UK Collaborative Group for HIV and STI Surveillance. Testing Times. HIV and other sexually transmitted infections in the United Kingdom: 2007. http://www.hpa.org.uk/webHPAweb&HPAwebStandard/HPAweb_C/1203084355941
8. Stöhr W, Dunn DT, Porter K et al. on behalf of the UK CHIC Study. CD4 cell count and initiation of antiretroviral therapy: trends in seven UK centres, 1997–2003. HIV Medicine, 2007, 8, 135–41.
9. Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4<200 cells/_L) with HIV infection. HIV Medicine, 2004, 5, 93–8.
10. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS, 2006, 20, 1447–50. http://www. aidsonline.com/pt/re/aids/pdfhandler.00002030-200606260-00012. pdf;jsessionid=LHGYMBT176T4KKms5qv9ynYGtQp7QnkvWryz QbJFB9jfm7v7Zz3v!1629792715!181195629!8091!-1
11. Vernazza P, Hirschel B, Bernasconi E et al. Les personnes séro positives ne souffrant d’aucune autre MST et suivant un traitment antirétroviral efficace ne transmettent pas le VIH par voie sexuelle (An HIV-infected person on antiretroviral therapy with completely suppressed viraemia (“effective ART”) is not sexually infectious). Bulletin des Médecins Suisses, 2008, 89(5), 165–9. http://www.saez.ch/pdf_f/2008/2008-05/2008-05-089.PDF
12. Sex Transm Infect 2004;80:247-248 doi:10.1136/sti.2003.007682

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