Tackling late HIV diagnosis: Lessons from the UK in the COVID-19 era.

INTRODUCTION: Late diagnosis of HIV is associated with increased morbidity and mortality, and an increased risk of non-infectious comorbidities. On a societal level, late diagnosis leads to higher treatment and healthcare costs and is a major driver of HIV transmission. Despite improvements in other areas of the HIV care pathway, late diagnosis remains an individual and public health concern globally. OBJECTIVE: To examine the barriers to HIV testing and highlight successful strategies to improve prompt diagnosis. This review describes the prevalence of late diagnosis in the UK and discusses key factors that contribute to late diagnosis, including the effect of the COVID-19 pandemic. Late HIV diagnosis is lower in the UK than in most other European countries. In this review, pilot projects and ongoing initiatives that have reduced late diagnosis in the UK are highlighted; moreover, further strategies for improving prompt diagnosis are suggested. CONCLUSIONS: Insufficient testing is the fundamental reason for late HIV diagnosis, with societal, systemic, and individual factors all contributing to inadequate testing. Improving access to testing, removing barriers to health-seeking behaviour, and ensuring all people with HIV indicator conditions are promptly tested are key to reducing the rates of late diagnosis globally.

Total protein, albumin and low-molecular-weight protein excretion in HIV-positive patients.

BACKGROUND: Chronic kidney disease is common in HIV positive patients and renal tubular dysfunction has been reported in those receiving combination antiretroviral therapy (cART). Tenofovir (TFV) in particular has been linked to severe renal tubular disease as well as proximal tubular dysfunction. Markedly elevated urinary concentrations of retinal-binding protein (RBP) have been reported in patients with severe renal tubular disease, and low-molecular-weight proteins (LMWP) such as RBP may be useful in clinical practice to assess renal tubular function in patients receiving TFV. We analysed 3 LMWP as well as protein and albumin in the urine of a sample of HIV positive patients. METHODS: In a cross-sectional fashion, total protein, albumin, RBP, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) were quantified in random urine samples of 317 HIV positive outpatients and expressed as the ratio-to-creatinine (RBPCR, CCR and NGALCR). Exposure to cART was categorised as none, cART without TFV, and cART containing TFV and a non-nucleoside reverse-transcriptase-inhibitor (TFV/NNRTI) or TFV and a protease-inhibitor (TFV/PI). RESULTS: Proteinuria was present in 10.4 % and microalbuminuria in 16.7 % of patients. Albumin accounted for approximately 10 % of total urinary protein. RBPCR was within the reference range in 95 % of patients while NGALCR was elevated in 67 % of patients. No overall differences in urine protein, albumin, and LMWP levels were observed among patients stratified by cART exposure, although a greater proportion of patients exposed to TFV/PI had RBPCR >38.8 µg/mmol (343 µg/g) (p = 0.003). In multivariate analyses, black ethnicity (OR 0.43, 95 % CI 0.24, 0.77) and eGFR <75 mL/min/1.73 m2 (OR 3.54, 95 % CI 1.61, 7.80) were independently associated with upper quartile (UQ) RBPCR. RBPCR correlated well to CCR (r2 = 0.71), but not to NGALCR, PCR or ACR. CONCLUSIONS: In HIV positive patients, proteinuria was predominantly of tubular origin and microalbuminuria was common. RBPCR in patients without overt renal tubular disease was generally within the reference range, including those receiving TFV. RBP therefore appears a promising biomarker for monitoring renal tubular function in patients receiving TFV and for distinguishing patients with normal tubular function or mild tubular dysfunction from those with severe renal tubular disease or Fanconi syndrome.

Identification and characteristics of vulnerable adults attending an inner city sexual health service.

Adult safeguarding is the function of protecting vulnerable adults from abuse or neglect. The 2012 Department of Health Draft Care and Support Bill highlighted adult safeguarding as a key government priority and stated that a clear framework is required for organisations dealing with 'adults at risk'. Adults at risk present to sexual health services but no formal guidance currently exists to aid their identification and management in this setting. We conducted a retrospective case note review which identified that vulnerable adults attend our service. They may display recognised risk factors, awareness of which is likely to facilitate identification and assessment of this group and aid appropriate onward referral.

Immunodeficiency and renal impairment are risk factors for HIV-associated acute renal failure.

OBJECTIVE: To identify risk factors for acute renal failure (ARF) in HIV-infected patients. DESIGN: Observational cohort study of HIV-infected patients attending a South London HIV centre between January 1999 and December 2008. METHODS: ARF was defined as a transient, more than 40% reduction in renal function as assessed by estimated glomerular filtration rate. Multivariate Poisson regression analysis was used to identify baseline and time-updated factors associated with ARF. RESULTS: The incidence of ARF was 2.8 (95% confidence interval 2.41-3.24) episodes per 100 person-years. We observed a stepwise increase in ARF incidence with time accrued at lower CD4 cell count and at lower estimated glomerular filtration rate, with adjusted incidence rate ratios of 1 (reference), 1.56 (0.97-2.48), 2.08 (1.11-3.91), 6.38 (3.18-12.78) and 10.29 (5.11-20.98) for CD4 cell counts of more than 350, 201-350, 101-200, 51-100 and of 50/microl or less, and 1 (reference), 1.46 (0.86-2.51), 4.19 (2.37-7.42) and 27.00 (16.13-44.95) for estimated glomerular filtration rate more than 90, 75-89, 60-74 and less than 60 ml/min, respectively. Ethnicity, hepatitis B or C coinfection, exposure to combination antiretroviral therapy with or without indinavir, tenofovir or atazanavir and HIV viraemia were not associated with ARF. CONCLUSION: Current levels of immunodeficiency and renal function were independent predictors of HIV-associated ARF.