46 | Nursing in Practice | Autumn 2023
1
Is there any reason to offer Amanda a test for HIV today ?
A Yes B No
2
You arrange a variety of tests , including HIV , and a few days later the lab calls to inform you that Amanda ’ s HIV test is positive . She is shocked to hear this news , and you arrange for her to be seen in the HIV clinic within a couple of days . Her main concern is that she wants to conceive soon – she currently uses condoms for contraception . Her partner had a recent work medical that included an HIV test , which was negative . What can you tell her ?
A If her partner remains HIV negative then they will need to have fertility assistance to conceive , as it won ’ t ever be safe for him to have unprotected sex with her .
B Once she begins treatment , the risk of transmission to her partner will drop significantly , but it won ’ t ever be zero . It will be up to him if he wants to take the risk of having unprotected sex .
C Once she has been on treatment for six months and has an undetectable viral load she cannot pass HIV to her partner and they can stop using condoms .
QUICK QUIZ Unexpected HIV result
SCENARIO You are seeing Amanda , a 35-year-old woman who has come for her smear test . She mentions that she has lost about 5kg over the past couple of months , without trying to lose weight , and she wasn ’ t overweight in the first place . She also has some diarrhoea , which has been present for about three weeks
1 2 3 4 5
By Dr Toni Hazell , a GP in north London
3
Amanda mentions that she has a six-year-old daughter from a previous relationship , who was born in the UK . She had an HIV test at her booking appointment for that pregnancy but hasn ’ t had another until the positive one that you arranged . Does her child need to be tested for HIV ?
A Yes B No
4
Amanda goes on to antiretrovirals and has another two children . At the age of 48 she comes to see you with menopausal symptoms . She is keen to start HRT . Other than her HIV , she has no medical problems , she is a non-smoker , her blood pressure and BMI are normal , and she has no family history of note . Can she be started on HRT in primary care ?
A Yes B No
C You don ’ t have enough information to decide
5
Amanda ’ s smear test comes back normal – she has never had an abnormal one . When does she next need a smear test ?
A In three years B In 18 months C In one year D In five years
Answers . 1 A . NICEadvises offering an HIV test to anyone who presents with an indicator condition 1 , which include pneumonia , cervical dysplasia , hepatitis A , B and C , unexplained fever or weight loss or unexplained chronic diarrhoea . 2 2 C . Undetectable = untransmittable denotes there is no risk of transmission from a person on antiretrovirals for at least six months who has an undetectable viral load . This has helped reduce stigma , allowing those with HIV to date without fear of passing on the virus , and encouraging adherence to antiretrovirals . 3 , 4 , 5 You tell Amanda her HIV should not be a barrier to conceiving . 3 A . HIV testing is now standard at the booking appointment , but is not repeated later in pregnancy or after breastfeeding . If Amanda contracted HIV during pregnancy or breastfeeding , she could have passed it to her daughter , who needs an HIV test . Her daughter is asymptomatic and guidance suggests Amanda can be given up to a year , with support , to agree to a test , after which refusal would become a child protection issue . 6 Amanda wants to discuss this with her HIV consultant and you await the next letter , in which the consultant reports having liaised with paediatrics to arrange a test , which was negative . For infants under one year , testing is more urgent , as they are at risk of rapid disease progression . 4 A . With life expectancy now normal for those with treated HIV , there is an increasing cohort of women of menopausal age . The PRIME study 7 found a high prevalence of menopausal symptoms in women with HIV . HRT can be prescribed in the normal way , although higher doses may be needed if there are interactions with antiretrovirals . 5 C . Women with HIV are at a higher risk of cervical cancer and need annual smears . Your smear form should have a box to indicate that the woman has HIV ( it may say ‘ retroviral disease ’) – ticking it will mean the lab automatically recalls each year . If there is no such system locally you ’ ll need your own practice recall system to ensure women with HIV do not accidentally default to the three- or five-yearly recalls .
References 1 NICE QS157 . HIV testing : encouraging uptake . nice . org . uk / qs157 2 British HIV Association . Adult HIV Testing Guidelines 2020 . tinyurl . com / BHIVA-BIA-BASHH 3 Rodger AJ et al . PARTNER study . JAMA . 2016 ; 316 ( 2 ): 171-81 . tinyurl . com / Rodger-Partner 4 Rodger AJ et al . PARTNER2 study . Lancet . 2019 ; 393:2428-2438 . tinyurl . com / Rodger-Partner2 5 Terrrence Higgins Trust . Can ’ t pass it on . tinyurl . com / THT-CPIO 6 CHIVA . HIV testing guidelines for children of HIV positive parents and / or siblings in the UK and Ireland . tinyurl . com / CHIVA-test 7 Tariq S et al . PRIME ( Positive Transitions Through the Menopause ) study . BMJ Open . 2019 ; 9 ( 6 ): e025497 . tinyurl . com / BMJO-Prime
ALAMY