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2003 audit of new HIV diagnoses
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2003 audit of new HIV diagnoses

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  • NB 2001 audit finding was confirmed by 2002 audit. Data is as follows:
    Of patients starting treatment for the first time, the proportion with CD4 <200 was 62%, 66%, 66% in 2000, 2001, and 2002 respectively.
    The proportions with CD4 <50 were 27%, 30%, 24%.
  • White patients were 91% male, whereas Black African patients were 65% female.
  • Clear trend towards earlier diagnosis in Whites compared with Black Africans.
  • NB: on the questionnaire, GUM/sexual health centre and “Non-GUM HIV centre” were two separate options. 22 patients from 6 centres were described as diagnosed at “Non-GUM HIV centres”.
    Answers are self-defined, but it is likely that most infectious diseases clinics classified themselves as medical out-patients rather than HIV centres.
  • Clear trend towards low CD4 in those diagnosed as medical IP.
  • NB only one circumstance has been recorded per patient. In 25 cases the respondent ticked both “Routine screen – GUM” and another reason (22 concern about risk, 1 diagnosis of symptomatic disease, 2 investigation of other signs) – these cases have been recorded under the other reason rather than screening.
    Overall, the 3 purely “routine screening” categories accounted for 41% of diagnoses. This rises to 43% if we include cases where routine screen and another reason were both ticked.
  • NB this classification must be treated with caution – information was quite limited in many cases.
    Reason given is primary one – not more than one classification per patient.
  • Some patients attended more than one service.
  • Symptom categories were applied retrospectively and have to be treated with caution.
    Where more than one symptom category was reported for the same patient, one was classified as “primary” on the basis of likely clinical significance and relevance to HIV.
  • This data is based on write-in comments, and was not sought specifically.
  • Transcript

    • 1. BHIVA national clinical audit of HIV diagnosis Dr Margaret Johnson, Chair of BHIVA clinical audit committee Dr Gary Brook Vice-Chair of BHIVA clinical audit committee Dr Hilary Curtis, BHIVA clinical audit co-ordinator Committee: R Brettle, P Bunting, D Daniels, A Freedman, B Gazzard, C O’Mahony, E Monteiro, D Mital, F Mulcahy, A Pozniak, C Sabin, A Sullivan, A Tang, J Welch, E Wilkins
    • 2. New diagnosis audit preliminary results Case note review of new diagnoses of HIV:  Diagnosed at participating centres Jan-March 2003  Or first seen at participating centres Jan-March 2003 having been diagnosed elsewhere less than 2 months before. Rationale:  Follow-up of 2001 audit finding that most patients first started treatment at CD4 <200, but that this was associated with late diagnosis  Explore possible reasons for late or missed diagnosis.
    • 3. Participation Data were analysed on 977 newly diagnosed patients submitted by 98 participating centres. Patients were:  540 (55%) male, 434 (44%) female, 3 not stated  576 (59%) black African, 320 (33%) white, 66 (7%) other, 15 not stated  660 (68%) heterosexually infected, 278 (28%) homo/bisexual, 12 (1%) IDU, 5 other, 22 not stated.  21 (2%) aged 15-19, 312 (32%) aged 20-29, 444 (45%) aged 30-39, 153 (16%) aged 40-49, 32 (3%) aged 50-59, 12 (1%) aged 60+, 3 not stated.
    • 4. Sex by ethnicity 0 100 200 300 400 White Black African Numberofpatients Male Female p=0.0001
    • 5. Other patient characteristics Of the 977 patients:  89 (9%) were known to be recent arrivals in the UK  A further 19 (2%) were returning UK nationals  Only 10 (1%) were reported to be short term visitors. True figures may be higher as information may be incomplete and recent arrival was defined as within two months prior to diagnosis.  711 (73%) patients were reported to be registered with a GP  162 (17%) were not registered  Information was missing for 104.
    • 6. Disease state at diagnosis: Stage Total CDC A 57% CDC B 25% CDC C 15% NK/missing 3% Total 100% CD4 Total 0-50 11% 51-200 20% 201-350 24% 351-500 18% 500+ 19% NK/missing 8% Total 100%
    • 7. CD4 at diagnosis by ethnicity 0% 5% 10% 15% 20% 25% 30% 35% 0-50 51-200 201-350 351-500 500+ CD4 at diagnosis %ofpatients White Black African p=0.0003
    • 8. Place of diagnosis Of the 977 patients:  667 (68%) were diagnosed in GUM/sexual health or HIV centres  107 (11%) as medical in-patients  84 (9%) in antenatal clinics  47 (5%) in general practice  27 (3%) as medical out-patients  38 (4%) in other places, including 8 via NBTS, 4 at insurance medicals, and 2 each in A&E, fertility clinics, private clinics and TOP clinics  The place of diagnosis was not stated for 7 (1%).
    • 9. NBTS diagnoses The eight patients reported as diagnosed via blood transfusion services were all male and included:  5 Whites, 2 Black Africans, 1 other  5 heterosexuals, 3 homo/bisexuals. One was a sero-convertor, having given a negative donation five months earlier.
    • 10. CD4 by where diagnosed 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% GUM/sexual health or HIV centre GP AN clinic Medical OP Medical IP Other Total CD4 %ofpatients 0-50 51-200 201-350 351-500 500+ NK/missing
    • 11. Circumstances of diagnosis 33% 29% 16% 9% 7% 3% 2% Test because of concern about risk GUM screen Diagnosis of symptomatic disease AN screen Investigation of other abnormal signs Other routine screen NK/missing
    • 12. Hospitalisations A total of 162 (17%) patients were reported to have either been diagnosed as medical in-patients, or to have been admitted to hospital in the year preceding diagnosis:  107 were diagnosed as in-patients, of whom 20 also had an admission in the previous year  A further 55 were diagnosed outside hospital after having been admitted in the previous year.
    • 13. Hospitalisations, continued Of 75 patients admitted in the year before diagnosis, the reasons for admission were described as:  “very likely or definitely” HIV-related for 38 (51%)  “possibly” HIV-related for 20 (27%)  “not” HIV-related for 12 (16%)  Information was missing for 5 (7%).
    • 14. Reasons for hospitalisation Reasons for hospitalisation in patients who were either diagnosed as in- patients, or who had been admitted in the year to diagnosis, were classified as follows:  39 patients with opportunistic infections  21 with infections which were not clearly opportunistic  11 with reasons for admission not directly related to HIV  6 each with sero-conversion and with symptomatic HIV disease  3 with genito-urinary conditions  2 each with malignancies and haematological conditions  1 each dermatological and PGL  8 other.
    • 15. Other HIV-related conditions 170 (17%) patients were reported as having had other possibly HIV-related conditions/symptoms in the year prior to diagnosis.  Of these 170 patients, 128 did not also have a reported hospital admission prior to or at diagnosis.  17 had an admission prior to diagnosis, 15 were diagnosed as in-patients and 10 fell into both these categories.
    • 16. Service usage Of the 170 patients who were reported as having possibly HIV- related non-in-patient symptoms/conditions in the year before diagnosis, 129 were known to have sought care from at least one service:  71 had attended general practice  37 had attended hospital out-patients  20 had attended a GUM/sexual health clinic  16 had attended other services  22 were reported as “self-care only – did not seek medical attention”.
    • 17. Reported symptoms/conditions Non-in-patient symptoms reported in the year to diagnosis were classified as follows:  48 GU conditions (32 classed as “primary” condition, 9 attended GP, 15 attended GUM)  43 opportunistic infections (42 primary, 18 attended GP)  33 symptomatic HIV disease (21 primary, 15 attended GP)  23 seroconversion (18 primary, 11 attended GP)  22 infections (17 primary, 13 attended GP)  17 dermatological conditions (11 primary, 10 attended GP)
    • 18. Reported symptoms/conditions Continued:  14 haematological conditions (8 primary, 3 attended GP)  11 PGL (7 primary, 4 attended GP)  4 not directly HIV-related (1 primary, 0 attended GP)  2 malignancies (2 primary, 0 attended GP)  1 hepatitis C (primary, did not attend GP)  8 other (6 primary, 4 attended GP)
    • 19. Missed diagnoses? The circumstances of diagnosis for the 75 patients admitted to hospital in the year previous to diagnosis were as follows:  18 routine screening (14 GUM, 1 AN, 3 other), including 4 whose admission was “very likely or definitely” HIV-related and 7 “possibly” HIV-related.  17 concern about risk  22 diagnosis of symptomatic disease  18 investigation of other abnormal signs. This suggests that in at least some cases the diagnosis was not made as part of the follow-up of the admission.
    • 20. Missed diagnoses? - continued Similarly, of the 143 patients who had symptoms but not a hospital admission in the year to diagnosis, circumstances of diagnosis were as follows:  42 routine screen (31 GUM, 8 AN, 3 other)  41 concern about risk  40 diagnosis of symptomatic disease  17 investigation of other abnormal signs.
    • 21. Other reported findings 9 patients were reported as lost to follow-up after diagnosis but not known to have left the UK. 5 patients were reported to have died. All were Black African. One had PCP, one had KS, one had group A strep septicaemia & pericardial sepsis, and one had cerebral toxoplasmosis (data uncertain, but probably developed after diagnosis of HIV).
    • 22. Conclusions This audit shows continuing evidence of late diagnosis of HIV infection, and potentially avoidable disease. As expected, black African patients were diagnosed later than whites. Routine screening accounted for less than half of diagnoses – further steps may be needed to increase screening uptake. Although the course of events was unclear in many cases, there is also some evidence of delayed diagnosis after patients have presented with symptomatic disease.