Simultaneous with the development of these guidelines, a multi-agency group, led by WHO, has been developing a tool to aid in the diagnosis of HIV/AIDS skin conditions. While the emphasis in these guidelines is on treatment, the tool focuses in addition on diagnosis, and therefore serves as a useful complement to these recommendations. It is described here as an additional resource for the target audience set out above.1
The development of this tool initially involved three steps:
PubMed review and ranking of prevalence of HIV-associated diseases in adults and children;
Identification of all existing algorithms and guidelines for diagnosis of HIV-associated skin conditions which included 17 national documents (seven from Asia, six from Africa, four from the Caribbean/Latin America), WHO guidelines and three textbooks; and
Development of an algorithmic tool.
The algorithmic tool was developed through expert opinion by clinical dermatologists working in HIV dermatology in India, South Africa, the United Kingdom and USA.
There were two iterations in the development of the algorithmic tool. The first iteration was developed using three different approaches that diagnosed 45 diseases (oral and genital diseases excluded). The three approaches included a topography map (disease by distribution on the body), a decision-making tree and a picture atlas (see WEB APPENDIX 2). Practitioners use the tool by first identifying basic morphology and then using one of the above approaches or a combination of them.
After input from dermatologists in the field, the tool was refined to include better diagnostic criteria, additional diagnoses of relevance and additional pictures of children and of skin diseases in diverse subjects.
This tool was designed to include the three approaches mentioned above and was formatted into large laminated cards that hang on a ring. These cards may either be distributed to individual practitioners or hang from the wall in a clinic setting.
To test the utility of this tool, field surveys were conducted in clinics in Moshi, United Republic of Tanzania; Durban, South Africa; Kampala, Uganda; and Eldoret, Kenya. Patients on whom the tool was used included HIV-infected children and adults, both on ART and not yet taking it. Practitioners completed both a global and an individual survey to determine user-friendliness, the overall approach and the usefulness of the tool to reach a diagnosis. The diagnoses by field practitioners were compared to a dermatologist’s diagnosis in a small pilot study in which surveys and pictures were sent electronically through a smartphone device.
The decision-making tree and picture atlas were considered the most helpful and useful parts of the tool, while the topography maps were less frequently used. There was 90% agreement between field practitioners and the dermatologist in the pilot study.
The tool was presented for discussion at the GDG meeting in Geneva in September 2013. The next iteration of the tool will include skin diseases that are seen worldwide and need to be differentiated from HIV-related skin diseases. In addition, conditions which alert the practitioner that HIV testing is necessary and those in which there is special consideration for biopsy will be highlighted. This tool will be produced more widely, with plans for further field testing for ease of use and diagnostic validity.
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Note that some of the conditions in the algorithm could be severe enough to require hospitalization. Referral should be considered if there is no response after treatment is initiated.
