NEW HIV diagnoses have remained steady over the past 5 years at just over 1000 a year nationwide, as reported in the Kirby Institute’s HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2017. This report was presented in Canberra at the 2017 Australasian HIV and AIDS Conference.
Male-to-male sex continues to be the major HIV risk exposure and is associated with 70% of HIV diagnoses; 21% of diagnoses result from heterosexual transmission. There are increasing diagnoses in Indigenous people and in Asian-born gay and bisexual men. This highlights the ongoing need to discuss risk factors, such as sexual behaviour, with all new patients. At-risk patients then need to be offered HIV testing and prevention, which remains demanding for busy GPs.
Undiagnosed HIV presents some tough challenges. In 1993, the MJA ran a series of articles (Could it be HIV?); almost 25 years later, an estimated 11% of people living with HIV remain undiagnosed, with a third of new HIV diagnoses in people presenting late, often when they are unwell. Late presentation is associated with being older, female, heterosexual, born overseas or living in rural and remote areas. Late diagnosis of HIV results in delayed treatment, with increased morbidity and mortality and the potential for HIV transmission to sexual partners.
Dr Yi Dan Lin and colleagues performed a retrospective review of patients hospitalised with a late diagnosis of HIV infection. Over 40% of patients had an “indicator” symptom prior to diagnosis, with the most common conditions being unexplained weight loss, herpes zoster, thrombocytopenia or leukopenia, oral or oesophageal candidiasis, community-acquired pneumonia and sexually transmitted infection. Most patients had these symptoms for at least 3 months prior to hospital admission. The study suggested a potential benefit in applying the European AIDS Clinical Society testing guidelines for indicator conditions in the Australian context, which is supported by the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine’s (ASHM) indications for HIV testing.
It is encouraging that we are seeing a decline in new HIV diagnoses in some states, such as NSW, probably related to the scale up of preventive activities, including the use of PrEP (pre-exposure prophylaxis), as well as earlier diagnosis and treatment. PrEP involves people at risk of HIV taking antiretroviral medication to prevent infection, an approach that has proved to be highly effective in preventing HIV transmission. Over 7000 people in NSW are receiving PrEP through the EPIC trial, with similar initiatives in other states. Associate Professor Edwina Wright explored practical aspects of expanding PrEP into general practice, which is likely to follow an anticipated Pharmaceutical Benefits Scheme listing in 2018. Preparing GPs to provide PrEP will be a new challenge for ASHM and other training organisations.
Following HIV diagnosis, all people are now encouraged to start antiretroviral medication as soon as possible, with data in NSW finding 59% of people with a new HIV diagnosis having started treatment within 6 weeks. Early, lifelong treatment is associated with excellent health outcomes as well as preventing transmission of HIV to sexual partners.
How do we incorporate routine HIV testing into our practice?
We need to continue to offer regular HIV and sexual health screening for at-risk groups, particularly gay and bisexual men. But we also need to widen our clinical vision to offer testing to other groups, including Indigenous people, people born overseas or travelling from overseas countries and those with unexplained symptoms. The challenge is in how to incorporate HIV testing into our routine practice, given the benefits of early diagnosis and treatment.
A take-home message from this meeting is that we always need to think “could it be HIV?”
Dr David Baker is the HIV clinical advisor to the ASHM, and he is a general practitioner with a special interest in sexual health, based at East Sydney Doctors.
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