Constitutional symptoms (weight loss/diarrhoea, fever) and lymphadenopathy

Compared to less specific ‘constitutional’ symptoms, unexplained lymphadenopathy has the most robust evidence base for routine HIV testing. The evidence base for constitutional symptoms as HIV IC is mixed due to limitations in recording and coding of symptoms.  Unexplained weight loss of >10% is an AIDS-defining illness and is therefore a strong indication to test for HIV, particularly in the presence of any other IC. Diarrhoea alone (without weight loss) has been a common symptom of those presenting with late diagnosis of HIV in Scotland and lends itself to automated prompts on tests sets, but has not been included as an IC in recent studies informing guideline development. Diarrhoea presenting with weight loss has not been examined as an IC in any published study, but would be regarded as a very strong indicator for HIV testing. Sexually transmitted diarrhoea (termed STEI – sexually transmitted enteric infection¹⁹) is often unrecognised and may be associated with higher risk sexual exposure – testing for HIV, if negative, may provide an opportunity for a discussion and referral for HIV PrEP.  

Include prompts to test for HIV on  

• Investigation test order for lymphadenopathy and infectious mononucleosis 
• Diarrhoea test sets (eg tTG) 
• Weight loss (there appear to be few standard test sets/ guidelines on unexplained weight loss) 

Include recommendations to test for HIV in 

• Clinical guidelines on management of lymphadenopathy, diarrhoea, malignancy referral guidelines 
• Health Protection guidance on management of enteric infections 
• Rapid Cancer Diagnostic Service (RCDS) pathways 
  • Include HIV in standard referral test order sets and/or 
  • Include HIV testing at first clinic visit 
• Teaching materials on lymphadenopathy, diarrhoea, weight loss and malignancy. 

In the HIDES 2 study, HIV was newly diagnosed in 4.3% of those with unexplained lymphadenopathy. It was strongly associated with an increased OR of HIV infection in Lee et al⁹ and in a UK based General Practice Case-control study². 

In the HeLP registry study (which included confirmed outpatient diagnoses), unexplained weight loss was associated with a HIV rate of 0.38% (0.21–0.56) The rate was higher in those aged 30-60 yrs; 0.82% (0.41–1.29) than under 30 years; 0.18% (0–0.55) or over 60 years; (0.05%). It was associated with an increased OR of HIV infection in Lee et al⁹ and a UK General Practice based case-control study². Unexplained weight loss was the indicator condition most commonly identified as a missed opportunity for testing in a recent review of 164 cases of very late HIV diagnosis in the UK⁵.

Diarrhoea was not included as an IC in HIDES¹⁶, HIDES 2¹², HeLP³ or Lee et al⁹; consequently in the draft UK HIV Testing Guideline it has a Grade 2C recommendation. It was the IC seen most commonly in the year before HIV infection in a UK General Practice based case-control study, 7.1% of those diagnosed consulting with at least 1 episode of diarrhoea². It has also been commonly identified as a symptom in morbidity and mortality reviews of people with late HIV diagnosis in Scotland and in the recent cases of very late HIV diagnosis in the UK. Unpublished systematic review evidence supports the addition of sexually transmitted enteric infections (STEI) to the list of indicator conditions in the forthcoming UK HIV testing guidelines⁵.

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

• Unexplained swollen glands  

Swollen glands: example text

Swollen glands is a health condition that occurs more often in people living with HIV. If you have swollen glands that have not got better after 2 weeks, and no other cause for them has been found, you should be offered an HIV test. If 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 swollen glands that have not got better after two weeks and no other cause has been found, can help with early diagnosis, treatment and preventing passing it on.  

Shigella: example text

Shigella is a health condition that occurs more often in people living with HIV. If you have shigella that may have been passed on through sex, you should be offered an HIV test. If 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 shigella that you think was passed on through having sex can help with early diagnosis, treatment and preventing passing it on.