Multidisciplinary Clinical Case Study

Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease

Authors: Nathaniel Forrester, BA, Jonathan Zhang Suo Keyes, MD, Ronan Cajimat, MSN, AGACNP-BC, Yelena Burklin, MD, MA, Mary Ann Kirkconnell Hall, MPH, Jason Cobb, MD

Abstract

Approximately 158,500 adults and adolescents in the United States live with undiagnosed human immunodeficiency virus (HIV). Missed or delayed diagnoses adversely affect disease management and outcomes. This is particularly salient for patients receiving immunosuppressive and immunomodulatory therapy for the management of chronic inflammatory conditions, in which additional immunosuppression may increase the risk and severity of opportunistic infections. Despite this risk, comprehensive HIV testing before the initiation of immunosuppressive therapy is not yet the norm. We describe a case series containing the narratives of three patients recently treated with immunosuppressive agents, who presented with signs concerning for HIV-associated kidney diseases and who were found to have undiagnosed HIV later in the treatment course, which, unfortunately, resulted in poor outcomes. Screening for HIV or related illnesses, such as viral hepatitis or mycobacterial co-infections including tuberculosis, is essential before initiating biologic immunosuppression.

 
Posted in: Infectious Disease143 Acquired Immunodeficiency Syndrome (AIDS) And Human Immunodeficiency Virus (HIV) Infection20

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Centers for Disease Control and Prevention. HIV Surveillance Report. Diagnoses of HIV infection in the United States and dependent areas 2020. https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-33/index.html. Accessed May 8, 2023.
 
2. Claytor JD, Viramontes O, Conner S, et al. TNF-α inhibition in the setting of undiagnosed HIV infection: a call for enhanced screening guidelines. AIDS 2021;35:2163–2168.
 
3. Jefferson JA. Complications of immunosuppression in glomerular disease. Clin J Am Soc Nephrol 2018;13:1264–1275.
 
4. Lucas S, Nelson AM. HIV and the spectrum of human disease. J Pathol 2015;235:229–241.
 
5. Li J, Thompson TD, Tai E, et al. Testing for human immunodeficiency virus among cancer survivors under age 65 in the United States. Prev Chronic Dis 2014;11:E200.
 
6. Owens DK, Davidson KW, Krist AH, et al. Screening for HIV infection: US Preventive Services Task Force Recommendation statement. JAMA 2019; 321:2326–2336.
 
7. Holroyd CR, Seth R, Bukhari M, et al. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis—executive summary. Rheumatology (Oxford) 2019;58:220–226.
 
8. Kucharzik T, Ellul P, Greuter T, et al. ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease. J Crohns Colitis 2021;15:879–913.
 
9. Gilani B, Vaqar S. HLA B 5701 Testing. Treasure Island, FL: StatPearls Publishing; 2023.
 
10. Swanepoel CR, Atta MG, D’Agati VD, et al. Kidney disease in the setting of HIV infection: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies conference. Kidney Int 2018;93:545–559.
 
11. Girardi E, Sabin CA, Monforte AD. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr 2007;46(Suppl 1):S3–S8.
 
12. Patel D, Johnson CH, Krueger A, et al. Trends in HIV testing among US adults, aged 18-64 years, 2011-2017. AIDS Behav 2020;24:532–539.
 
13. Soh QR, Oh LYJ, Chow EPF, et al. HIV Testing uptake according to opt-in, opt-out or risk-based testing approaches: a systematic review and metaanalysis. Curr HIV/AIDS Rep 2022;19:375–383.
 
14. Dailey AF, Hoots BE, Hall HI, et al. Vital Signs. Human immunodeficiency virus testing and diagnosis delays—United States. MMWR Morb Mortal Wkly Rep 2017;66:1300–1306.
 
15. Kobrak P, Remien RH, Myers JE, et al. Motivations and barriers to routine HIV testing among men who have sex with men in New York City. AIDS Behav 2022;26:3563–3575.
 
16. Anderson S, Friedman EE, Eller D, et al. HIV testing in a high prevalence urban area in the US: identifying missed opportunities two ways. Int J STD AIDS 2022;33:970–977.
 
17. Reif S, Safley D, McAllaster C, et al. State of HIV in the US Deep South. J Community Health 2017;42:844–853.
 
18. Martínez Sanz J, Pérez Elías MJ, Muriel A, et al. Outcome of an HIV education program for primary care providers: screening and late diagnosis rates. PLoS One 2019;14:e0218380.
 
19. García-Ruiz de Morales AG, Martínez-Sanz J, Vivancos-Gallego MJ, et al. HIV and HCV screening by non-infectious diseases physicians: can we improve testing and hidden infection rates?. Front Public Health 2023;11:1136988.
 
20. Tan K, Black BP. A systematic review of health care provider-perceived barriers and facilitators to routine HIV testing in primary care settings in the southeastern United States. J Assoc Nurses AIDS Care 2018;29:357–370.
 
21. Aaron E, Alvare T, Gracely EJ, et al. Predictors of linkage to care for newly diagnosed HIV-positive adults. West J Emerg Med 2015;16:535–542.
 
22. Marks G, Gardner LI, Craw J, et al. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS 2010;24:2665–2678.
 
23. Clifton DC, Clement ME, Holland TL, et al. Suboptimal HIV testing among patients admitted with pneumonia: a missed opportunity. AIDS Educ Prev 2017;29:377–388.
 
24. Wanyenze RK, Nawavvu C, Namale AS, et al. Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. Bull World Health Organ 2008;86:302–309.
 
25. Osorio G, Hoenigl M, Quartarolo J, et al. Evaluation of opt-out inpatient HIV screening at an urban teaching hospital. AIDS Care 2017;29:1014–1018.
 
26. Costello J, Carpentier M, Sliney A, et al. Evaluation of a nurse-initiated routine HIV testing pilot on a medical-surgical unit. Medsurg Nurs 2016;25:36–43.
 
27. Costello JF, Sliney A, MacLeod C, et al. Implementation of routine HIV testing in an acute care hospital in Rhode Island: a nurse-initiated opt-out pilot project. J Assoc Nurses AIDS Care 2013;24:460–468.
 
28. Detsis M, Tsioutis C, Karageorgos SA, et al. Factors associated with HIV testing and hiv treatment adherence: a systematic review. Curr Pharm Des 2017;23:2568–2578.
 
29. Pharr JR, Lough NL, Ezeanolue EE. Barriers to HIV testing among young men who have sex with men (MSM): experiences from Clark County, Nevada. Glob J Health Sci 2015;8:9–17.
 
30. Gurnik H, Engstrom CW, McCabe SE, et al. Differences in HIV testing among sexual orientation subgroups in the United States: a national crosssectional study. Prev Med Rep 2023;34:102230.
 
31. James TG, Ryan SJ. HIV knowledge mediates the relationship between HIV testing history and stigma in college students. J Am Coll Health 2018;66: 561–569.
 
32. Mannheimer SB, Wang L, Wilton L, et al. Infrequent HIV testing and late HIV diagnosis are common among a cohort of black men who have sex with men in 6 US cities. J Acquir Immune Defic Syndr 2014;67: 438–445.
 
33. Darlington CK, Hutson SP. Understanding HIV-related stigma among women in the southern United States: a literature review. AIDS Behav 2017;21:12–26.
 
34. Sangaramoorthy T, Jamison A, Dyer T. Intersectional stigma among midlife and older Black women living with HIV. Cult Health Sex 2017;19: 1329–1343.
 
35. Washio Y, Novack Wright E, Davis-Vogel A, et al. Prior exposure to intimate partner violence associated with less HIV testing among young women. J Interpers Violence 2021;36(5-6):np2848–np2867.
 
36. Smith S, Zhang X, Basile K, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 data brief – updated release. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf. Published November 2018. Accessed May 8, 2023.
 
37. Stockman JK, Lucea MB, Cimino AN, et al. Discrimination, resilience, and HIV testing frequency among black women seeking services from STD clinics. Soc Sci Med 2023;316:115344.
 
38. Walter AW, Morocho C. HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women. Int J Environ Res Public Health 2021;18:4535.
 
39. Geter A, Herron AR, Sutton MY. HIV-related stigma by healthcare providers in the United States: a systematic review. AIDS Patient Care STDS 2018;32: 418–424.