AusDoc 19th Sept | Page 29

ausdoc. com. au 19 SEPTEMBER 2025

Figure 3. X-rays of ground glass opacities of pneumocystis pneumonia in two different patients. The X-ray on the left shows a much more subtle ground-glass appearance while the one on the right shows a much more gross ground-glass appearance mimicking pulmonary oedema.

Imaging lung manifestations of HIV / AIDS; Annals of Thoracic Medicine( 2020) 5( 4) 201: 201 / CC BY 4.0 / bit. ly / 3O1RNdh judgements or assumptions of clinician and / or patient may falsely reassure and can result in a missed opportunity for testing. Ideally HIV testing is systematised for many of these conditions and this is often already happening( eg, before starting chemo- or immune-therapeutic agents).

NORMALISING TESTING

IT is common for healthcare professionals who do not routinely offer HIV testing to feel uncomfortable or anxious when discussing this with patients, perhaps especially with patients who are well known to them. Ordering HIV serology is now routine in healthcare settings and does not need to be prefaced by a lengthy counselling process, with informed verbal consent acceptable.

Removing the stigma is vital, and normalising HIV testing as part of a battery of tests used to investigate undiagnosed symptoms is a crucial message for GPs to pass on to their patients. Remember that there is a‘ window period’ of about 6-12 weeks before an HIV test becomes positive after an exposure, so recommend repeating the test at this time if the exposure risk was recent. Not all patients are aware they have had an at-risk exposure.

It is also important to tell the patient how the result will be relayed( eg, telehealth, text message or faceto-face appointment).

This is also an opportunity to test for other BBVs, including hepatitis B and C, as well as routinely offering a sexual health screen for syphilis, chlamydia and gonorrhoea if appropriate.

EuroTest( formerly known as HIV in Europe) is an initiative that brings attention to the earlier diagnosis and care for people living with HIV, viral hepatitis, sexually transmitted infections and tuberculosis. EuroTest is involved in projects and collaborations with partners throughout Europe. In their guidance for implementing HIV testing, 12 they discuss the multifactorial barriers to early diagnosis( see box 3).

Box 3. Barriers to early diagnosis

• Patient factors:— Unaware or denial of risk.— Fear of stigma or discrimination.

— Access to services, including language barriers.

• Healthcare professional factors:

— Lack of knowledge around HIV / clinical indicator conditions.

— Not confident in offering a test.

— Fear of being accused of discriminatory actions.— Assuming patients may or may not be‘ at risk’. Source: EUROTEST 2012 12

Overcoming these barriers is essential to improve confidence in discussing and offering an HIV test in the community. Arranging an education session from the local Sexual Health Clinic may also be useful to facilitate a discussion on the latest updates in HIV healthcare.

Adopting an indicator-condition approach means that taking a sexual history is not a necessary prerequisite to HIV testing. Sometimes the sexual history is‘ unremarkable’ and the patient appears to be at low risk( eg, when in a long-term heterosexual relationship). This may falsely reassure the patient and the clinician, and the test is not requested. Raising awareness about HIV clinical indicator-condition testing and systematising testing into guidelines will ensure HIV testing is performed consistently and will remove the need for clinician judgements or assumptions.

WHAT IF MY PATIENT DECLINES AN HIV TEST?

IT is important to accept the patient’ s decision, while ensuring that adequate discussion and test information has been supplied beforehand. It is important to rule out HIV despite the lack of

Table 1. Indicator conditions for HIV testing

Sexually transmissible infections

Respiratory infections

Neurological diseases

Dermatological diseases

Gastroenterological diseases

AIDS-defining conditions

Tuberculosis Pneumocystis( see figures 2 and 3) Recurrent bacterial pneumonia

Cerebral toxoplasmosis Primary cerebral lymphoma Cryptococcal meningitis Progressive multifocal leukoencephalopathy

Kaposi sarcoma( see figures 4 and 5)

Persistent cryptosporidiosis Oesophageal candidiasis

Other conditions where HIV testing should be offered

Gonorrhoea, chlamydia, hepatitis B, hepatitis C, syphilis or any other sexually transmissible infection

Aspergillosis

Aseptic meningitis / encephalitis Cerebral abscess Space-occupying lesion of unknown cause Guillain – Barré syndrome Transverse myelitis Peripheral neuropathy Dementia Leukoencephalopathy

Severe or recalcitrant seborrhoeic dermatitis Severe or recalcitrant psoriasis( see figure 6) Multi-dermatomal or recurrent herpes zoster( shingles, see figure 7)

Chronic oral candidiasis Oral hairy leukoplakia( see figure 8) Chronic diarrhoea of unknown cause Weight loss of unknown cause Nontyphoidal salmonella( bacteraemia, osteomyelitis and septic arthritis), recurrent enteric salmonellosis, shigellosis or campylobacter Hepatitis B infection Hepatitis C infection

Gynaecology Cervical cancer Vaginal, vulval or cervical high-grade intraepithelial lesion

Haematology Any unexplained blood dyscrasia including:

· thrombocytopenia

· neutropenia

· lymphopenia

Ear, nose and throat Lymphadenopathy of unknown cause( see figure 9) Chronic parotitis Lymphoepithelial parotid cysts

Other Mononucleosis-like syndrome( primary HIV infection) Pyrexia of unknown origin Any lymphadenopathy of unknown cause Any sexually transmissible infection

Source: ASHM 9