HIV presents in a myriad of ways. How can a GP or Practice Nurse respond to the clues?
Retrospective reviews of GP records after new HIV diagnoses show that patients present in primary care with HIV-related conditions, but the significance is often missed.
The difficulty is that many of them are conditions commonly encountered in general practice and commonly viewed as harmless. These conditions may also respond to treatment.
The trusted ‘watch and wait’ approach is therefore not appropriate when HIV is a possible underlying cause. The clinician needs to be able to recognise, and then respond to, conditions associated with HIV.
Primary HIV infection - my registrar's story
Primary HIV infection - a flu-like illness – occurs just a few weeks after a patient has been infected with HIV. I learned about this in a course I went on, and I remember thinking that it would be pretty difficult to pick up. However I was impressed by the advantages of diagnosing HIV at this earliest of all stages, with the benefits to the patient (as well as the potential to stop, or limit, transmission). Because our practice serves an area with a high prevalence of HIV I ran a clinical meeting on the subject. We included all our doctors and nurses because any of the clinical team can be involved in assessing sore throat and flu-like illnesses on the phone or face to face.
We agreed that we would raise the subject of HIV whenever possible in patients with such illnesses, but that we would always try to consider HIV when arranging tests for possible glandular fever.
We discussed how one might raise the subject of HIV when faced with a patient with such an illness and agreed on some phrases. My favourite is:
"There are a number of viruses that may cause a sore throat illness such as yours, and one of the commonest is flu. However a bit less commonly it can be caused by glandular fever. Have you heard of this? Shall we do a test? Even more uncommonly a cause can be HIV. Do you think you could have been at risk of this in the last couple of months? Could I ask you some questions to assess your risk? Would you like a test?"
Just a few months after we had this meeting my registrar saw a man aged about 35 who had a bad sore throat, myalgia and fever. He had been unwell for a week. My registrar managed to raise the subject of HIV and take a history to assess risk. She established her patient had had unprotected sex 2-3 weeks before with another man who he had just met in a club. He was surprised when she mentioned HIV but she helped him understand the value of testing. The HIV test showed him to be HIV antigen positive and antibody negative: ie primary HIV infection was confirmed. Her patient is doing extremely well and is relieved his infection was diagnosed so early.
My registrar got a big boost of confidence – I asked her to present the case to the team. One of our nurses pointed out that the consultation – including the sexual history – might equally well have been conducted on the phone. We reflected that, whatever our fears, our patients will often react reasonably calmly to a discussion about a difficult topic.