Lennon et al’s clinical review of infectious mononucleosis recommends considering HIV testing in “high risk” groups, which they define as injecting drug users and men who have sex with men.[1] We disagree with this restricted indication.
The identification of risk factors for HIV infection is notoriously unreliable as a screening tool for deciding when to offer a test[2], In the HIDES 2 study, patients at 42 European centres that presented with mononucleosis were routinely offered an HIV test and 5.3% had undiagnosed HIV.[3] In London, primary care requests for a glandular fever screen underwent anonymous blinded testing for HIV and the prevalence was 1.3% (95% confidence interval 0.7 to 2.3%); 73% of the diagnoses had been missed at the primary care consultation.[4] Mathematical models estimate that it is cost-effective to test widely where the prevalence of undiagnosed HIV infection exceeds 0.1%.[5-7] In the United Kingdom, an estimated 107,800 people are currently living with HIV, of whom 24% have not been diagnosed.[8] European and national specialist societies concur that HIV testing should be offered to all patients with a mononucleosis-like syndrome[9,10]
Mononucleosis is clinically indistinguishable from acute (primary) HIV infection, and this represents an excellent opportunity for early HIV diagnosis. In the United Kingdom, patients who are diagnosed with HIV at an early stage (defined as a CD4 count of greater than 350 cells/mm3) have a life expectancy that is equal to the general population.[11] By contrast, late diagnosis is associated with opportunistic disease, markedly increased healthcare costs, and an increased risk of death.[12-13]
We believe that all patients presenting in any healthcare setting with a mononucleosis syndrome, regardless of identifiable risk factors, should be offered an HIV test. Furthermore, HIV testing should be routinely included in a glandular fever screening panel with an opt-out strategy for consent in view of the prevalence of undiagnosed HIV in patients with mononucleosis. Any healthcare professional should be competent to offer a test[9] and opportunities to diagnose the infection should not be missed.
1. Lennon P, Crotty M, Fenton JE. Infectious mononucleosis. BMJ. 2015 Apr
21;350:h1825.
2. Elmahdi R, Gerver SM, Gomez Guillen G, et al. Low levels of HIV test coverage in clinical settings in the U.K.: a systematic review of adherence to 2008 guidelines. Sex Transm Infect. 2014;90(2):119-24.
3. Kutsyna G. Which Conditions are Indicators for HIV testing across Europe :Results from the HIDES II Study. PS2/01 HepHIV 2014 Conference: HIV and Viral Hepatitis: Challenges of Timely Testing and Care. Barcelona, Spain. http://newsite.hiveurope.eu/Conferences/HepHIV2014-Conference/Presentati... (accessed 10 May 2015)
4. Hsu DT, Ruf M, O'Shea S, Costelloe S, Peck J, Tong CY. Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Med. 2013;14(1):60-3.
5. Lucas A, Armbruster B. The cost-effectiveness of expanded HIV screening in the United States. AIDS. 2013 Mar 13;27(5):795-801.
6. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med. 2005;352(6):586-95.
7. Yazdanpanah Y, Sloan CE, Charlois-Ou C et al. Routine HIV screening in France: clinical impact and cost-effectiveness. PLoS One. 2010;5(10):e13132
8. Yin Z, Brown AE, Hughes G, et al. HIV in the United Kingdom 2014 Report: data to end 2013. November 2014. Public Health England, London.
10. HIV in Europe. HIV Indicator Conditions:guidance for implementing HIV testing in adults in health care settings. Copenhagen, Denmark. http://hiveurope.eu/Portals/0/Guidance.pdf.pdf (accessed 10 May 2015)
11. May MT, Gompels M, Delpech V, et al. Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS. 2014;28(8):1193-202.
12. Simmons RD, Ciancio BC, Kall MM, et al. Ten-year mortality trends among persons diagnosed with HIV infection in England and Wales in the era of antiretroviral therapy: AIDS remains a silent killer. HIV Med. 2013;14(10):596-604
13. Nardone A, Delpech V, Gill ON, Fenton KA, Anderson J. HIV in the UK: test, test, and test again. Lancet. 2013 Nov 23;382(9906):1687-8.
Competing interests:
No competing interests
10 May 2015
Alexander J Stockdale
NIHR Academic Clinical Fellow in Infectious Diseases
Prof Anna Maria Geretti, Consultant in Virology and Infectious Diseases
Institute of Infection and Global Health, University of Liverpool
Rapid Response:
Re: Infectious mononucleosis
Lennon et al’s clinical review of infectious mononucleosis recommends considering HIV testing in “high risk” groups, which they define as injecting drug users and men who have sex with men.[1] We disagree with this restricted indication.
The identification of risk factors for HIV infection is notoriously unreliable as a screening tool for deciding when to offer a test[2], In the HIDES 2 study, patients at 42 European centres that presented with mononucleosis were routinely offered an HIV test and 5.3% had undiagnosed HIV.[3] In London, primary care requests for a glandular fever screen underwent anonymous blinded testing for HIV and the prevalence was 1.3% (95% confidence interval 0.7 to 2.3%); 73% of the diagnoses had been missed at the primary care consultation.[4] Mathematical models estimate that it is cost-effective to test widely where the prevalence of undiagnosed HIV infection exceeds 0.1%.[5-7] In the United Kingdom, an estimated 107,800 people are currently living with HIV, of whom 24% have not been diagnosed.[8] European and national specialist societies concur that HIV testing should be offered to all patients with a mononucleosis-like syndrome[9,10]
Mononucleosis is clinically indistinguishable from acute (primary) HIV infection, and this represents an excellent opportunity for early HIV diagnosis. In the United Kingdom, patients who are diagnosed with HIV at an early stage (defined as a CD4 count of greater than 350 cells/mm3) have a life expectancy that is equal to the general population.[11] By contrast, late diagnosis is associated with opportunistic disease, markedly increased healthcare costs, and an increased risk of death.[12-13]
We believe that all patients presenting in any healthcare setting with a mononucleosis syndrome, regardless of identifiable risk factors, should be offered an HIV test. Furthermore, HIV testing should be routinely included in a glandular fever screening panel with an opt-out strategy for consent in view of the prevalence of undiagnosed HIV in patients with mononucleosis. Any healthcare professional should be competent to offer a test[9] and opportunities to diagnose the infection should not be missed.
1. Lennon P, Crotty M, Fenton JE. Infectious mononucleosis. BMJ. 2015 Apr
21;350:h1825.
2. Elmahdi R, Gerver SM, Gomez Guillen G, et al. Low levels of HIV test coverage in clinical settings in the U.K.: a systematic review of adherence to 2008 guidelines. Sex Transm Infect. 2014;90(2):119-24.
3. Kutsyna G. Which Conditions are Indicators for HIV testing across Europe :Results from the HIDES II Study. PS2/01 HepHIV 2014 Conference: HIV and Viral Hepatitis: Challenges of Timely Testing and Care. Barcelona, Spain. http://newsite.hiveurope.eu/Conferences/HepHIV2014-Conference/Presentati... (accessed 10 May 2015)
4. Hsu DT, Ruf M, O'Shea S, Costelloe S, Peck J, Tong CY. Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Med. 2013;14(1):60-3.
5. Lucas A, Armbruster B. The cost-effectiveness of expanded HIV screening in the United States. AIDS. 2013 Mar 13;27(5):795-801.
6. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med. 2005;352(6):586-95.
7. Yazdanpanah Y, Sloan CE, Charlois-Ou C et al. Routine HIV screening in France: clinical impact and cost-effectiveness. PLoS One. 2010;5(10):e13132
8. Yin Z, Brown AE, Hughes G, et al. HIV in the United Kingdom 2014 Report: data to end 2013. November 2014. Public Health England, London.
9. British HIV Association, British Association of Sexual Health and HIV and the British Infection Society. UK national guidelines for HIV testing 2008. BHIVA, London. http://www.bhiva.org/documents/guidelines/testing/glineshivtest08.pdf (accessed 10 May 2015)
10. HIV in Europe. HIV Indicator Conditions:guidance for implementing HIV testing in adults in health care settings. Copenhagen, Denmark. http://hiveurope.eu/Portals/0/Guidance.pdf.pdf (accessed 10 May 2015)
11. May MT, Gompels M, Delpech V, et al. Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS. 2014;28(8):1193-202.
12. Simmons RD, Ciancio BC, Kall MM, et al. Ten-year mortality trends among persons diagnosed with HIV infection in England and Wales in the era of antiretroviral therapy: AIDS remains a silent killer. HIV Med. 2013;14(10):596-604
13. Nardone A, Delpech V, Gill ON, Fenton KA, Anderson J. HIV in the UK: test, test, and test again. Lancet. 2013 Nov 23;382(9906):1687-8.
Competing interests: No competing interests