Undocumented HIV Infection

IN RESPONSE:

We concur with Dr. Harrow's comments underscoring the need to carefully evaluate prisoners with undocumented HIV infection for malingering and to subsequently carefully document HIV status. We add another note of caution, however, regarding intravenous drug users. We know of two such patients who gave their hospital cards to a known HIV-infected person to have an HIV antibody test drawn in the hospital's central phlebotomy laboratory.

Andrews and coworkers raise several issues regarding the data and conclusions from our recent article [1]. In reference to the case–control study design, we also have concerns about self-reported data, but the data were extracted exclusively from medical records for the 7 cases and 70 randomly selected controls; therefore, inaccuracies should be similar in both groups.

We also recently addressed the prevalence rates of factitious HIV infection at our hospital. In 1994, we assessed the prevalence of HIV antibody in stored serum bank specimens from 105 randomly selected clinic patients with symptomatic HIV disease, stratified equally by CD4 lymphocyte count (< 200 cells/mm3, 201 to 499 cells/mm³, and more than 500 cells/mm³). Although all were positive for HIV antibody, suggesting no widespread factitious HIV disease, this was a selected group of patients who had advanced HIV disease and whose serum samples were stored for evaluation. Since publication of our article and institution of a policy to confirm HIV status, however, 7 additional patients (8.5%) with factitious HIV disease have been identified among the last 82 patients screened at our HIV Diagnostic Evaluation Unit during the past 6 months. All had CD4 counts greater than 600 cells/mm³.

Factitious HIV disease is probably more prevalent at high CD4 counts; however, we believe that clear documentation of HIV infection at any CD4 count is critical for the patient and clinician because of problems related to HIV testing, potential psychosocial issues, and other diseases that may mimic HIV infection [1-3]. In addition, the belief that a patient is HIV positive may affect clinical judgments, the patient's perception of his or her disease, and compliance with risk reduction. Furthermore, we have received correspondence from several health care providers who have experienced cases of factitious HIV disease, and we know of at least two physicians facing patient lawsuits for failure to clearly document HIV disease before initiating treatment. Finally, the cost of an HIV antibody test is insignificant compared with the expenditures for unwarranted primary care visits, associated entitlements, untoward effects on the patient, or possible litigation.

• Copyright ©2004 by the American College of Physicians