Editor – The recent lesson of the month by Menezes et al raises a number of issues (Clin Med October 2008 pp 550–1). Clearly, early consideration of HIV infection as a possible diagnosis is vital in unusual, undiagnosed cases if one is to prevent severe and serious consequences. This becomes even more important in a non-genitourinary setting, as in this case, and I am pleased to note that the authors emphasise this in their paper.
The article highlights the fact that while HIV may be an early consideration in certain marginalised groups and in individuals with certain behaviours, it still needs to be explored in cases with no obvious risk factors or in those who deny risky sexual behaviour. Clinicians need to take a non-judgemental and empathic approach to differing lifestyles when offering HIV testing and not an exceptional one as this creates further barriers. Non-HIV specialists challenging the exceptionalism associated with HIV testing will further allay patients' fears and concerns (which are real) and hopefully stop perpetuating the discrimination and stigma associated with an HIV diagnosis.
I am, however, disappointed that the authors made little attempt to trace the source of their patient's infection, concentrating instead mainly on the neurological issues. I am also concerned that disclosing the HIV status of the patient's sister and the fact that the patient cared for her during the terminal stages of her (sister's) illness, seems to suggest that the patient's HIV infection may have been contracted from her sister! This simply perpetuates one of the vast plethora of myths surrounding HIV infection. Equally disappointing is that no mention is made of whether the HIV specialist team was involved post-diagnosis. Something that may have happened years ago and been forgotten or something that the patient is in denial about or genuinely unaware of, always remains a possibility. Though rare, these instances do occur and highlight the need to involve the specialist team post-diagnosis who ensure that risk assessment and partner notification/contact tracing is dealt with in an appropriate manner. This, we know, is extremely important to prevent further transmission.