Missed opportunities for HIV diagnosis: a three-year audit in the West of Scotland.

BACKGROUND: National specialty guidelines for HIV testing aim to increase diagnosis and reduce late presentation. An audit of new HIV diagnoses in Glasgow was performed to assess local performance against these guidelines and estimate the proportion of patients presenting who had previous missed opportunities for diagnosis. METHODS: A retrospective case note review of 339 patients diagnosed from September 2008 to September 2011 was performed. Documented past medical history was assessed for HIV clinical indicator conditions prior to HIV diagnosis and prior review by medical services. RESULTS: Ninety (26%) individuals had at least one documented clinical indicator condition prior to HIV diagnosis, of whom 80 had prior contact with at least one speciality. This group also had a lower mean nadir CD4 count (258 cells/cmm versus 393 cells/cmm, p = <0.005) and were more likely to be severely immunocompromised at diagnosis, with a CD4 count below 50 cells/cmm (31% versus 9%, p = <0.005). AIDS-defining illnesses were also more common (31% versus 8%, p ≤ 0.005) as was HIV-related mortality (p ≤ 0.005). CONCLUSION: Additional support and training are required to increase adherence to HIV-testing guidelines within primary and secondary care in order to prevent ongoing late presentation with both individual clinical and public health implications.

An unexpected undetectable viral load in a vulnerable woman.

We present a case of a vulnerable HIV-positive African woman who on initial visits to the clinic had an undetectable HIV viral load without giving a history of being on antiretroviral therapy (ART) who then had an abrupt and significant rise in viral load and fall in CD4 count to below the recommended treatment level of 350 cells/µL. She gave a history of having been given a 'white tablet' from the man who had trafficked her. As genuine 'elite controllers' are rare and do not usually follow this pattern, we suspect that this woman was unknowingly on ART.