HIV infections are being missed in UK patients with suspected glandular fever

Michael Carter
Published: 18 May 2012

HIV infections in patients with suspected glandular fever are often missed, investigators from south London report in HIV Medicine. Retrospective testing showed that 1.3% of patients were infected with HIV and that three-quarters of these infections remained undiagnosed after presentation to a GP. The authors suggest that opt-out HIV tests should be offered to patients with glandular fever-like symptoms by GPs.  

Between a fifth and a quarter of HIV infections in the UK are undiagnosed. Late diagnosis is a major factor in many of the HIV-related deaths that still occur in the UK. Epidemiological surveillance also suggests that a substantial proportion of HIV transmissions originate in undiagnosed individuals. Increasing the uptake of HIV testing and the detection of undiagnosed infections is therefore a public health priority.

Primary care has an important role in the expansion of HIV testing. Many patients with primary HIV infection, or seroconversion illness, consult their GP, presenting with symptoms including fever, muscle aches, sore throat and rash. These non-specific symptoms can be mistaken for flu and also resemble the symptoms of glandular fever.

Prevalence of HIV in the south London boroughs of Lambeth and Southwark is between 1.13 and 1.39% and undiagnosed prevalence is 0.4%. Investigators wanted to see if HIV infections were being missed in patients screened for glandular fever by GPs in these two boroughs.

Their study sample comprised 1046 blood samples submitted for glandular fever screening between April 2009 and June 2010. Samples without an accompanying request for an HIV test were anonymously tested for the infection.

One patient was already known to be HIV-positive and was excluded for subsequent analysis.

A request for an HIV test was submitted at the same time as a request for glandular fever screening for 118 patients (11%). Three of these patients (3%) were found to be HIV-positive and one had recently acquired the infection.

“Results indicate low levels of HIV testing in patients presenting in primary care with glandular fever-like illness,” comment the authors.

A further 45 patients (4%) had a subsequent HIV test within a year of their glandular fever screen. Two patients undergoing routine antenatal screening were infected with HIV.

The HIV infection status was therefore unknown for 882 patients. Samples from 694 of these individuals were available for anonymous testing. This detected six undiagnosed HIV infections, three of which had been recently acquired.

“The overall positivity of 1.3% in our group presenting with glandular fever-like symptoms is substantially higher than the estimated undiagnosed prevalence [0.4%] in the local population,” emphasise the investigators. “We believe our results provide a strong economic case for including HIV in the standard glandular fever screening tests.”

They note “UK national guidelines…recommend screening if diagnosed HIV prevalence exceeds 2 per 1000 population. A prevalence of 1.3% in our glandular fever cohort is well above the recommended threshold for routine screening.”

The authors therefore conclude “local policy should consider adopting the same opt-out strategy as in antenatal screening and include an HIV test routinely within the glandular fever screening investigation panel.”


Hsu DTS et al. Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Med, online edition. DOI: 10.1111/j.1468-1293.2012.01023x, 2012.

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