Offering HIV tests to patients who present with glandular fever-like illness would improve the detection rate of HIV, a primary care study has shown.

The prevalence of HIV infection in patients presenting with glandular fever-like illness in practices in Lambeth and Southwark was studied. Samples submitted to the local laboratory for a glandular fever screen between April 2009 and June 2010, with and without a concomitant HIV request, were anonymised and retrospectively tested for HIV.

In total, 1,046 glandular fever screening tests were requested from GPs in 72 practices during the study period. Concomitant HIV tests were requested in 119 patients. One patient who was already HIV positive was excluded, so the rate of concomitant HIV test requests was 11.3% (118 out of 1,045).

Of the 118 tests, three tested positive for HIV (2.5%). A further 45 had an HIV test requested within a year through another consultation; and of these two tested positive (4.4%). Both were diagnosed through routine antenatal screening.

Of the 882 patients with unknown HIV status, 694 had samples available for unlinked HIV testing; six of these tested HIV positive (0.9%).

Overall HIV prevalence in this group was 1.3% (11 out of 857) with possibly eight of the 11 cases (72.7%) missed at initial GP consultations.

It appears that opportunities for HIV diagnosis were missed in some patients presenting with glandular fever-like illnesses in this study; this may mean a significant number of undiagnosed infections in high prevalence areas such as Lambeth and Southwark where diagnosed HIV prevalence is 1.39 and 1.13% respectively.

Primary HIV infection or seroconversion illness typically occurs two to four weeks after infection with HIV in 80% of individuals. It can last two to three weeks and may be the only clinical manifestation of HIV infection before advanced disease is detected many years later. The presentation is similar to that of glandular fever and it is well recognised that individuals with primary HIV infection often present with a glandular fever-like illness.

As GPs, we see many people of all ages presenting with glandular fever-like illness. The UK HIV testing guideline suggests an HIV test should be considered in investigation of patients with mononucleosis syndrome.

The authors advocate inclusion of HIV testing as part of glandular fever screening tests. They suggest adopting an opt-out strategy as in antenatal screening. This is an interesting proposition, particularly in areas of high HIV prevalence such as London and other urban areas where diagnosed prevalence is > 2 per 1,000. It would be an extra box to tick but it may save the lives of many.

Dr Richard Ma

• Hsu DTS, Ruf M, O’Shea S et al. Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Med 2012 DOI: 10.1111/j.1468-1293.2012.01023.x