32 HOW TO TREAT: HIV CLINICAL INDICATOR TESTING IN GENERAL PRACTICE
32 HOW TO TREAT: HIV CLINICAL INDICATOR TESTING IN GENERAL PRACTICE
19 SEPTEMBER 2025 ausdoc. com. au
T2 dermatomes on the right side
Diagnosing HIV infections early reduces mortality and morbidity.
of his back. His facial skin is generally dry with scaly patches affecting his forehead and eyebrows, consistent with seborrheic dermatitis.
The GP prescribes antiviral therapy and Andrew’ s shingles gradually resolves without post-herpetic neuralgia. Over the following weeks, managing his seborrheic dermatitis proves challenging, even with mild topical steroids. Andrew is referred to a dermatologist for consideration of specialist medication. The dermatologist orders further investigations for Andrew’ s refractory seborrheic dermatitis, including an HIV screen and autoimmune panel, and is considering a biopsy. Andrew ' s HIV serology is positive, which likely explains the severity and refractory nature of his seborrheic dermatitis.
Andrew is referred to the local sexual health service and full STI testing, including syphilis serology and baseline HIV workup, is performed. On further detailed questioning, Andrew reveals he had a causal sexual encounter with a male three years earlier but had not followed this with any testing. He denies any seroconversion illnesses.
Andrew’ s CD4 count on diagnosis is 180 cells / μL( normal range 500- 1500 cells / μL). His current female partner tests negative to HIV. Further contact tracing of the male from three years earlier is not successful, as it was an anonymous encounter. Andrew is started on ARVs.
How to Treat Quiz.
1. Which THREE have had an impact on reducing HIV numbers in Australia in the past decade? a Increased testing. b Increased use of condoms. c Treatment as prevention. d Pre-exposure prophylaxis.
2. Which TWO statements regarding HIV are correct? a Lifelong compliance with medication is key to ensuring an ongoing undetectable viral load. b Offer HIV testing to patients if they have persistent unexplained diarrhoea, multidermatomal shingles or community acquired pneumonia, even if there appear to be no traditional risk factors. c The highest notification rate of new HIV infections is in gay men born in Australia. d Traditionally, HIV testing has been offered to all populations.
3. In which THREE common situations should HIV testing be offered? a Unexplained thrombocytosis or lymphocytosis. b Persistent unexplained lymphadenopathy. c Multi-dermatomal shingles. d Anyone presenting with a mononucleosis-like syndrome.
4. Which THREE statements regarding clinical indicator testing for HIV are correct? a Common AIDS-defining conditions include oesophageal candidiasis, Kaposi sarcoma, pneumocystis pneumonia and cervical cancer. b There are cases where not testing for HIV can contribute to significant patient harm and morbidity. c The absence of an identified epidemiological or behavioural risk factor should not preclude HIV testing in appropriate clinical circumstances. d It is not possible to have more than one AIDS-defining condition at any one time.
5. Which THREE gynaecological conditions are NOT AIDSdefining conditions? a Vaginal high-grade intraepithelial lesion. b Vulval high-grade intraepithelial lesion c Cervical cancer. d Cervical high-grade intraepithelial lesion.
Case study two
Layla, a 47-year-old female, presents to her GP with ongoing painless, non-bloody diarrhoea that has been present for five weeks. She is opening her bowels 3-4 times per day and occasionally at night. She is fatigued enough to stop doing her
HIV CLINICAL INDICATOR TESTING IN GENERAL PRACTICE
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6. Which THREE are AIDS-defining respiratory conditions? a Tuberculosis. b Pneumocystis pneumonia c Recurrent bacterial pneumonia. d Aspergillosis.
7. Which are barriers to early diagnosis? a Lack of knowledge around HIV / clinical indicator conditions. b Unaware or denial of risk. c Fear of being accused of discriminatory actions. d Fear of stigma or discrimination.
8. Which THREE statements regarding HIV testing are correct? a It is important to accept the patient’ s decision if they decline an HIV test. b If the patient declines a test, it should not be offered again. c If a test is negative, this is a good opportunity for sexual health promotion. d Results are ideally discussed face to face, unless the patient is happy to do this on the phone.
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• RACGP points are uploaded every six weeks and ACRRM points quarterly. regular exercise classes. On further questioning, she estimates she has lost nearly 3kg during this period. Layla denies night sweats, fevers or lymphadenopathy. There is no history of recent foreign travel and her household contacts are well. She is not on any medication. Layla works
9. Which TWO statements regarding advising a positive HIV test are correct? a A positive results means you will have to look after the patient’ s HIV and become an S100 ARV prescriber. b As the ordering clinician, arrange for communication of the result as you would usually do for any testing. c When testing for HIV using the clinical indicator conditions method, the chance that a test is positive may be as little as 1 in 1000. d The pathologist will report results to the patient.
10. Which THREE statements regarding the prognosis of HIV are correct? a The presenting medical condition often improves once antiretroviral therapy is initiated. b Diagnosing HIV infection before immune depletion( that is, a CD4 count less than 350cells / μL) improves mortality and morbidity. c People in Australia living with HIV now have an assumed average life expectancy of 63 years. d Depending on how low the CD4 count is at diagnosis, patients may be at risk of immune reconstitution syndrome.
Dermnet NZ / bit. ly / 3UOj1rk
Figure 10. Hypopigmented seborrhoeic dermatitis in HIV. full-time in recruitment, is a nonsmoker, drinks alcohol very occasionally and has no children. She was married for 10 years and, after her divorce, has been with her current cis-gendered male partner for eight years.
The GP orders laboratory testing that reveals an FBC with a normal haemoglobin, platelets 125 x 10 9 / L( normal range 150-450 x 10 9 / L) and normal white cells. HbA1c is normal, as are iron studies, thyroid function tests, and liver and renal function. Tests for coeliac disease are negative, and a faecal calprotectin level is normal. A stool culture is negative. Layla undergoes a colonoscopy that is normal.
On further review because of ongoing symptoms, the GP orders HIV serology, which is positive. Layla’ s only previous HIV test was performed 10 years earlier, when she was pregnant. The test was negative and the pregnancy terminated in a miscarriage.
Her CD4 count at diagnosis is 100 cells / μL( normal range 500-1500 cells / μL).
Contact tracing is undertaken. Layla’ s current male partner tests positive and likely acquired HIV on one of his many work / holiday trips to Thailand several years earlier.
Both Layla and her partner are started on ARVs.
CONCLUSION
THE quest to unearth the remaining undiagnosed HIV infections within Australia must be relentless if the goal of eliminating new transmissions by 2030 is to be reached.
New HIV infections are rising in traditionally non-high-risk groups, who are often presenting late with numerous missed opportunities for testing in the years before diagnosis.
Diagnosing HIV infections early reduces both mortality and morbidity; it is also cost-effective in our continually stretched health service.
An indicator-condition testing approach in both primary care and in non-GP specialist settings, such as ED, will aid earlier detection of cases. This offers an opportunity for rapid treatment, improving both patient and public health outcomes in Australia.
In addition to routine testing in sexual health clinical encounters, moving towards HIV testing based on medical indicator conditions is strongly recommended, and is cost-effective.
RESOURCES
• Australian STI Management Guidelines sti. guidelines. org. au
• ASHM tool. Could it be HIV? bit. ly / 4gm97Fj
• ASHM General Practitioners and HIV resource bit. ly / 42Hsfuu
• ASHM S100 HIV prescriber course information bit. ly / 4hHIbAX
• Health Equality Matters healthequitymatters. org. au
• National Association of People with HIV Australia( NAPWA) and National Network of Women Living with HIV napwha. org. au
References Available on request from howtotreat @ adg. com. au