Community acquired pneumonia

Pneumonia is strongly associated with HIV infection in those <65 years. There is some variation in the definition of pneumonia in studies of IC testing. Some studies have included only hospital admissions for over 24 hours and/or radiologically confirmed diagnosis, others have included only two episodes of confirmed pneumonia (two episodes of pneumonia is an AIDS-defining condition in people who are HIV positive). Other registry-based studies have used all diagnostic codes in all areas. Pneumonia lends itself to a whole-system approach system-wide testing policies and prompts (eg at diagnosis, x-ray request, treatment) and our recommendation is to apply systems/prompts to all confirmed cases of pneumonia. Different studies have included single or recurrent episodes of pneumonia and for methodological reasons, largely included those who are admitted to hospital. For these reasons we recommend testing in all confirmed diagnoses of pneumonia with an upper age limit for routine testing of 65 years. However, testing should never be ruled out on the basis of age alone. There is an argument to have NO upper age limit on IC testing in pneumonia. ED opt-out testing in England identified a small but important number of people newly diagnosed with HIV aged 65-79 (around 7% of total new diagnoses).

Include prompts to test for HIV on  

• radiology requests which query pneumonia
• radiology reports showing pneumonia 
• microbiology reports on positive sputum samples 
• prescribing guidance for inpatient and outpatient treatment of pneumonia 
• respiratory referral guidelines (recurrent pneumonia, suspected TB, and malignancy) 

Include recommendations to test for HIV in 

• Clinical guidelines on management of pneumonia
• Teaching materials on respiratory diseases 

In the HIDES 2 study¹², HIV was newly diagnosed in 3.3% of those diagnosed with pneumonia. In the HeLP registry study³ (which included confirmed outpatient diagnoses), the rate was higher in men 1.22% (1.03–1.42) than in women 0.57%(0.44–0.71) and also higher in those over 60 than under 60 years, although the lower 95% confidence interval exceeded 0.1% in all age groups. Bacterial pneumonia was the IC most strongly associated with HIV infection in a UK General Practice based case-control study². In a US based study of HIV testing in those diagnosed with pneumonia with an upper age limit for inclusion of 65 years, a quarter of patients newly diagnosed with HIV were over 58 years¹⁸. The demographic profile of individuals diagnosed with HIV through the ED testing programme in England is older than those diagnosed in other settings, with a late diagnosis rate of 50%. Scottish data (NHS Lothian) shows that 20% of late diagnoses are over the age of 60 years. There is therefore no clear upper age limit to apply to IC testing, including for pneumonia. 

Information on Indicator Conditions is included in pages on NHS Inform: HIV

• Pneumonia 

Example text:

Pneumonia is a health condition that occurs more often in people living with HIV. If you have been diagnosed with pneumonia and you are under the age of 65, you should be offered an HIV test. If you have been diagnosed with pneumonia but you haven't been offered an HIV test you can: 

• speak to your healthcare provider about getting tested for HIV
• get a free test using one of these options 

Testing for HIV when you have pneumonia can help with early diagnosis, treatment and preventing passing it on.