Misdiagnosis of HIV infection: implications for universal testing
Maddux, Dawn Ea; Reibero, Peter Fa; Kheshti, Ashgara,b; Sterling, Timothy Ra; Raffanti, Stephen Pa,b
aDivision of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
bComprehensive Care Center, Nashville, Tennessee, USA.
Received 28 September, 2007
Accepted 17 October, 2007
A 38-year-old heterosexual male was referred for evaluation of recently diagnosed HIV infection. The subject had a positive enzyme-linked immunosorbent assay (ELISA) and indeterminate western blot for HIV as part of a routine blood donation. His primary care physician confirmed the positive ELISA serology and referred him to the Comprehensive Care Center for evaluation and treatment of HIV infection. The patient reported no known risk factors for HIV infection and had no significant past medical history. A more detailed review of his prior testing revealed two positive HIV ELISA tests and two indeterminate western blot immunoassay results within 3 weeks of presentation to the clinic. Subsequent testing (undetectable plasma HIV-1 RNA) confirmed that the subject was not HIV-infected.
Few case study reports have been performed to examine patients who are referred to healthcare facilities with an HIV misdiagnosis [1,2]. Most of these were limited to malingering or Munchausen's syndrome in relation to HIV. Here, we retrospectively investigated numerous variables in such patients in search of defining characteristics in a false-positive HIV population. The data are pertinent to analyses of cost of care, stress to the patient, as well as utilization of AIDS service organizations.
This case prompted review of all patients referred to the Comprehensive Care Center for HIV care who were subsequently determined to be HIV-uninfected. The study population included all patients seen at the Comprehensive Care Center from August 1997 until 30 June 2007. Of 4450 patients referred, 51 were subsequently determined to be HIV-uninfected by undetectable plasma HIV-1 RNA, CD4 positive lymphocyte count within normal limits, and repeat ELISA. A single abstracter reviewed all 51 charts and associated records. The characteristics of these subjects are shown in Table 1.
HIV negative subjects referred for care were similar to the aggregate patient population with respect to age (median of 35 years and 37 years, respectively) but were more likely to be female (57% versus 24%, P < 0.001) and less likely to be African–American (18% versus 36%, P < 0.001). Of the 33 individuals who presented with appropriate screening tests, 19 (58%) had missing or misinterpreted confirmatory testing. Of the entire group, only six (12%) were self referred with no prior documentation of screening tests, and 36 (71%) were referred by medical clinics or subspecialists. Four were referred to the Center already on antiretroviral therapy and three were also already receiving services from AIDS service organizations.
Case reports have suggested that malingering and secondary gain may be a common cause of false HIV diagnoses [3,4]. Our data suggest that most subjects referred to a regional HIV treatment center with an erroneous diagnosis of HIV infection were referred by healthcare providers after initial positive screening tests. Although 14 (27%) of the cohort had prior psychiatric diagnoses, none were diagnosed with malingering or Munchausen syndrome and, unlike prior case reports, they did not appear to be a factor in these referrals. The false diagnosis of HIV infection can lead to significant costs and unnecessary utilization of resources. With the recent guidelines promoting HIV screening as part of general health maintenance [5–7], providers and HIV specialists should be aware of the potential for the misdiagnosis of HIV infection if confirmatory testing guidelines are not followed appropriately.
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