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Latin America( 25 % each). The estimated
proportion with undiagnosed HIV was also higher in people with reported risk exposures of heterosexual sex( 15 %) and injection drug use( 13 %), and lower among men with male-to-male sex as their HIV risk exposure( 7 %)”. 4
Australian public health goals are outlined in the 8th National HIV Strategy( 2018-2022) with the 9th edition pending. Australia continues to work towards the 95-95-
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Box 1. Clinical indicator conditions
• Conditions that are AIDSdefining.
• Conditions associated with undiagnosed HIV prevalence of greater than 0.1 %.
• Conditions where not identifying HIV infection will have significant implications, for example, pre-chemotherapy or pre-immunomodulating agents.
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95 targets as described at the Joint United Nations Programme on HIV / |
Source: EUROTEST HIV indicator conditions 2012 12 |
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AIDS( UNAIDS): 95 % of people living | ||||
with HIV aware of their status, 95 % |
of people diagnosed on treatment, and 95 % of those people diagnosed on treatment with an undetectable |
Box 2. Common situations in general practice where HIV testing should be offered |
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viral load. |
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Australia is currently estimated to be at 93 %, 95 % and 98 %, respectively, so there is still work to be done to find those unaware of their HIV status. 5
To reach the goal of the elimination of new transmissions by 2030, healthcare professionals must narrow their focus to finding those with an undiagnosed HIV infection.
More than half( 59 %) of notifications attributed to heterosexual sex were diagnosed late, indicating the importance of initiatives to raise awareness about HIV testing. 4 The overall proportion of those who were categorised as late HIV diagnoses in 2022( 44 %) was one of the highest since 1990 and is a continuation of a longer-term trend, reinforcing the need for improved access to testing among at-risk populations to reduce the time between HIV acquisition and diagnosis. 4
The proportion of late diagnoses in 2022 was 44 %, with HIV acquisition likely to have been at least four years before diagnosis. 4 The highest proportion of these late diagnoses in 2021 / 2022 were attributed to heterosexual sex. 4
When reviewing the medical journey of patients with a late diagnosis of HIV, it is not uncommon to unearth multiple missed opportunities for testing where contact was made with medical services, both in
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• Unexplained thrombocytopenia or lymphopenia.
• Persistent unexplained lymphadenopathy.
• Anyone presenting with a mononucleosis-like syndrome; this could be HIV seroconversion and a chance for rapid diagnosis and treatment initiation. Syphilis can also present with these symptoms.
• Recommend anybody with a sexual health infection to undergo an HIV test and syphilis test, if not already done.
• Multi-dermatomal shingles, unexplained weight loss or chronic unexplained diarrhoea.
HIV means that, even in the absence of an apparent risk factor, this test is done.
This How to Treat discusses the clinical conditions in which HIV testing should be considered. It aims to ensure GPs can feel confident recommending and offering HIV testing for their long-term patients with clinical indicator conditions and perhaps an absence of‘ traditional’ HIV acquisition risk factors.
CLINICAL INDICATOR CONDITIONS
AUSTRALIAN STI guidelines now
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Figure 2. Pneumocystis pneumonia. If left untreated, chest X-ray may progress to alveolar consolidation in three or four days. Infiltrates clear within two weeks, but in a proportion infection will be followed by coarse reticular opacification and fibrosis. Note the large cyst( arrow). |
Figure 1. HIV-positive serology.
Imaging lung manifestations of HIV / AIDS; Annals of Thoracic Medicine( 2020) 5( 4) 201: 201 / CC BY 4.0 / bit. ly / 3O28eGa
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primary and secondary care. Missed |
recommend HIV and syphilis test- |
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diagnoses result in increased mor- |
ing as part of all standard STI testing, |
factor should not preclude HIV test- |
prevalence and based purely on their |
to significant patient harm, such as |
tality, morbidity and cost to the public health sector— eliminating HIV transmission by 2030 is estimated to |
whenever STI testing is indicated. 7 This works towards the goal of eliminating HIV transmission and com- |
ing in appropriate clinical circumstances. 8 Finding undiagnosed cases of HIV infection necessitates a change |
clinical condition. Anecdotally, there have been cases where this diagnosis has been missed. |
before the initiation of chemo- or immunotherapy. Immunosuppressive therapy may further impair the |
save $ 1.4 billion. 4 |
bats the concerning rise in syphilis |
in testing strategy to one including |
In addition, ASHM lists several |
immune system of somebody liv- |
In a cohort study in 2018 explor- |
notifications in Australia. |
testing based on clinical indicators, |
non-AIDS-defining clinical indica- |
ing with HIV, with negative conse- |
ing missed diagnoses in Australia, |
The current HIV serology test is a |
especially in primary care settings. |
tor conditions( commonly seen in |
quences. In addition, the response |
those presenting with STIs, mental |
fourth-generation HIV antibody / anti- |
Clinical indicator conditions appear |
general practice) where HIV testing |
to treatment may be impaired if HIV |
health or drug-related diagnoses, |
gen test, and clinicians can request |
in box 1 and table 1. ASHM has pro- |
should be offered, including severe |
is not controlled. Routinely include |
non-infective gastrointestinal disorders and older people were more |
“ HIV serology”. If the test is positive( see figure 1), the laboratory will |
duced a comprehensive list of conditions prompting clinicians to order |
or recalcitrant seborrhoeic dermatitis, multi-dermatomal or recurrent |
testing in the workup for conditions requiring immunosuppressive |
likely to have had a missed opportu- |
automatically proceed to a series of |
HIV serology( see table 1). 9 |
herpes zoster / shingles, chronic diar- |
treatment. |
nity for diagnosis. 6 Traditionally, HIV testing has been offered to priority at-risk populations, including gay and bisexual men who have sex with men, and people who inject drugs. While male-to-male sex made up 57 % of |
confirmatory tests, either the more specific test, western blot in most cases, or occasionally, plasma HIV-1 nucleic acid testing via polymerase chain reaction( PCR).
PCR is highly sensitive and specific in the diagnosis of early HIV
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Testing for HIV infection is currently considered cost effective, even when the prior likelihood of positivity is as low as 1 in 1000. |
The clinical indicator testing strategy is evidence-based, as reported in a recent systematic review that looked at the outcomes of indicator-condition-driven testing in European hospitals. 10 In this study, the prevalence of undiagnosed HIV |
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new diagnoses in 2022, up to 30 % |
( this may require a second blood |
in the indicator-condition-driven |
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of HIV transmissions were attrib- |
sample and the laboratory would be |
Clinicians are well versed with |
rhoea of unknown cause, and weight |
testing rate was greater than 0.1 %. 10 |
uted to heterosexual contact and |
in contact with the practitioner). It |
common AIDS-defining conditions. |
loss of unknown cause( see box 2). 9 |
Testing for HIV infection is cur- |
3 % to injection drug use alone. The |
is usual practice that the laboratory |
These include oesophageal candid- |
Immune suppression is a driver |
rently considered cost effective, even |
remaining 10 % of cases are listed as |
then contacts the requesting practi- |
iasis, Kaposi sarcoma, pneumocys- |
for a poor treatment response or |
when the prior likelihood of positiv- |
other / unspecified. 1 |
tioner with a positive result, and in |
tis pneumonia( PCP) and cervical |
worsening of the presenting condi- |
ity is as low as 1 in 1000, so the per- |
Testing outside of sexual health |
many cases will inform the clinician |
cancer, which are fortunately rare |
tion. Diagnosing and initiating HIV |
ceived risk does not have to be high |
services has previously focused on |
of the support that is available to the |
in Australia. It is possible to have |
treatment promptly can ameliorate |
to test. 11 |
a risk assessment of behaviour, and |
practitioner in giving the patient the |
more than one AIDS-defining condi- |
the underlying indicator condition, |
Explaining to patients that“ it is |
in many cases of delayed diagnoses, |
result, and also the specialist referral |
tion at any one time. It is important |
diminish further immune decline |
our routine practice to rule out HIV |
the patient may be unaware of their |
pathways available. |
to exclude HIV in people diagnosed |
and prevent onward transmission. |
infection in anyone with symptoms |
risk. Following the clinical indicator |
The absence of an identified epi- |
with these conditions, despite a lack |
Finally, there are cases where |
or a condition such as this” helps |
testing recommendations to exclude |
demiological or behavioural risk |
of perceived risk or background HIV |
not testing for HIV can contribute |
to normalise HIV testing. Pre-held |