Intended for healthcare professionals


London hospital says it will continue to offer HIV tests to all accident and emergency patients after trial

BMJ 2011; 342 doi: (Published 13 June 2011) Cite this as: BMJ 2011;342:d3705

Failure to recognise probable HIV seroconversion illness in the over 60 year age group

Caroline White (13 June 2011)1 reports routine offering of HIV tests
at one London accident and emergency department , soon to be followed by
one other, and at a medical unit in Manchester, in a bid to curb onward
transmission of infection through detection of undiagnosed cases. Das et
al (27 November 2010)2 discussed primary HIV infection as an "easily
missed" condition, and described a 19 year old male who was hospitalised
with an acute illness, initially not recognised to be primary HIV
infection. We have seen a very similar case whose
HIV infection was diagnosed only when the patient attended to donate blood three
weeks after discharge from hospital after being investigated for a "viral
illness". Our recent experience suggests that opportunistic offers of HIV
testing should be more widespread, based on our experience with three
individuals in an older age group, where the opportunity to diagnose early
HIV infection was missed, despite them all presenting to medical care with
what we believe was their primary HIV infection illness .

All three individuals were repeat blood donors over the age of 64,
two male and one female, with established HIV infection. All three had
seroconverted since their last attendance to give blood. In each case,
careful history-taking undertaken by the donor care teams at the time of
notification of the positive test results revealed an illness compatible
with symptoms of HIV seroconversion for which the donor had previously
sought medical attention. In no case was the illness recognised, or HIV
testing performed.

Two of the donors had been seen by their General Practitioners, while the third had been admitted to hospital and underwent lymph node biopsy. The final diagnosis for two was "a viral infection" while the third was treated with antibiotics for a gastro-intestinal infection. Two of the three donors reported to us a new sexual partner shortly before the onset of the illness: in one case no sexual history had been taken, despite a previous history of sexually transmitted infection acquired abroad, while in the second a history was taken but HIV testing was not suggested. The third donor had a clearly identifiable life style risk but no history had been taken.

Despite coming to medical attention at the time of their illness of
seroconversion, none of our donors was recognised to have a primary HIV
infection illness. It is likely that their HIV infection would have gone
unnoticed for years until they became symptomatic again with disease
progression had they not been blood donors. One of them had reached the
previous retirement age for blood donors, but following removal of the
upper age limit (70 years) was able to continue blood donation and thus
benefit from early diagnosis of HIV infection. The donor who had declared
a lifestyle risk would not have been eligible to donate blood again unless
the donor's partner was willing to be tested for evidence of HIV infection. The partner tested positive - as a result both donor and partner were diagnosed as being infected.

These three older individuals (and the young patient) donated blood in
different parts of England, but all of them lived outside London, two of
them in rural areas. There may be less awareness of HIV infection outside
London and other large conurbations. The two oldest donors of our series
had given multiple blood donations prior to their seroconversion illness
(77 and 92 donations) and might therefore have been seen as "low risk" as
they had been tested many times in the past. They may also have perceived
themselves to be low risk.

The high rates of late diagnosis of HIV infection in adults over the
age of 50 has recently been described3 and these three donors, aged over
64, lend support to the concern that risk of HIV infection, and more
specifically, HIV seroconversion illness, is not being recognised or, more
importantly, even being considered in this age group. Lifestyle risks
should be explored more readily and a high index of suspicion maintained
in all cases of "non-specific viral infection"

1. London hospital says it will continue to offer HIV tests to all
accident and emergency patients after trial. White C. BMJ 2011: 342:d3705

2. Easily missed? Primary HIV infection. Das G, Baglioni P and
Okosieme O. BMJ 2010. 341: 1159 - 1160.

3. HIV transmission and high rates of late diagnosis among adults
aged 50 years and over. Smith Ruth D, Delpech Valerie C, Brown Alison E
and Rice Brian D. AIDS 2010. 24: 2109 - 2115.

Competing interests: No competing interests

05 July 2011
patricia e hewitt
Consultant Specialist in Transfusion Microbiology
Rekha Anand; Catherine Chapman; Nicola Hewson; Su Brailsford; Richard Tedder
NHS Blood and Transplant