Initial Evaluation is a topic covered in the Johns Hopkins HIV Guide.

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CLINICAL RECOMMENDATION

Medical History 

  • HPI: include date of Dx, date of infection if known, nadir CD4, peak VL, OIs and Sxs (stage HIV)
  • PMH: include prior TB or exposure, PPD history, chicken pox, shingles, residence and travel, mental health (e.g. depression screening), weight change.
  • Meds: ARV history (if any), OTCs, dietary supplements, methadone
  • Vaccinations: dT, Pneumovax, hepatitis B and A, and flu (seasonal)
  • Substance use: street, prescribed, recreational, needle-sharing, alcohol use (with CAGE or AUDIT), smoking
  • Sexual history: practices, barrier use, HIV status of partners, STDs
  • Social: Family/partner violence, HIV status of partner & children (if any) social support, diet, exercise, education
  • Allergies: sulfonamides, penicillin, hypersensitivity to prior ARVs and any other relevant medication allergies.
  • Family history: early CVD, diabetes, hyperlipidemia
  • Women: menstrual history, contraception, infertility, pregnancy history, childbearing plans , osteoporosis Dx and treatment.

Physical Exam 

  • Women: Include pelvic/rectal, breast exam. Condyloma, HSV, fungal, cervical dysplasia (PAP), Trichomonas, Chlamydia and GC, HPV
  • Men: Include prostate/rectal, genital exam. Condyloma, HSV. Consider anal PAP (HPV, dysplasia), especially in MSM.
  • Skin: KS, fungal, folliculitis, prurigo nodularis
  • Body habitus: fat redistribution (neck, face, breasts, buttocks, abdomen, extremities)
  • Oropharynx: candidiasis, OHL, KS, aphthous ulcers, periodontal disease.
  • Lymphadenopathy: localized requires evaluation; generalized common in HIV+
  • Neurologic: cognitive dysfunction , neuropathy, focal neurologic findings

Laboratory Assessment

  • HIV serology: if lab confirmation (serology, elevated VL) not available
  • CD4 count: stage HIV. Every 3-6 mos if not on ART
  • VL (plasma HIV RNA): stage HIV. Every 3-4 mos if not on ART
  • RPR: repeat annually or more often in pts at high risk
  • Chemistries: include AST, ALT, BUN, creatinine, bilirubin, alk phos, albumin, electrolytes
  • CBC with differential
  • Fasting blood glucose (x2): Consider 2-hr OGTT if abnormal.
  • Fasting lipid profile (TG, TC, HDL, LDL): all or prior to starting ARVs
  • Urinalysis: Proteinuria may indicate HIV-related or other early renal disease (e.g. HTN, DM).
  • C. trachomatis and N. gonorrhea by NAAT (all sexually active pts or w/ Sx).
  • HIV genotype (if VL >1000). Indicated regardless of need for ART, as mutations may disappear.
  • G6PD: consider before use of dapsone, primaquine, sulfonamides, especially in pts at risk (African or Mediterranean descent)
  • Hepatitis serologies: A (total anti-HAV Ab), B (HBsAg, HBsAb or HBcAb, with HBeAg/HBeAb and HBV DNA if HBsAg+; HBV DNA if HBcAb+/HBsAb- or if elevated LFTs ), and C (anti-HCV, with HCV PCR if anti-HCV+ or negative with risk factors or elevated LFTs).
  • anti-Toxoplasma IgG: evaluate for latent Toxoplasma infection. Counsel seronegative pts on avoiding exposure
  • anti-CMVIgG: in non-MSM, non-IDU. (MSM and IDU highly likely to be seropositive)
  • anti-varicella IgG: in pts with no history of chicken pox or shingles
  • AM Testosterone level (total): if clinical indication (weight loss, fatigue, loss of libido)
  • Pregnancy test: missed menses
  • PSA: Recommended for men >40 yo (AUA). Routine screening not recommended (ACA and USPSTF); no PSA screening after age 75 (ACS)

Procedures

  • Ophthalmologic fundoscopy: if CD4 < 50 or with visual Sx
  • Chest x-ray: If PPD+ or if clinically indicated. Not routine.
  • Cervical PAP: repeat at 6 mos, then annually if negative. Refer for colposcopy if abnormal.
  • Anal PAP: consider, especially in MSM or women with history of anal intercourse. Repeat every 1-3 years. Refer for high resolution anoscopy if abnormal.
  • Anthropomorphic measures: skin-fold, extremity/neck/abdomen circumference. BIA or DEXA: not standardized; BIA can’t distinguish visceral vs SQl fat. DEXA best for SQ, not visceral fat.
  • PPD: repeat annually in pts at risk; repeat after immune reconstitution on ART if initial PPD negative with low CD4.
  • Vaccinations: dT (every 10 yr), Pneumococcal (one time revaccination 5 years after 1st dose; consider repeat every 5 yrs though efficacy unknown, influenza (annual), hepatitis B and A (if non-immune). Vaccine efficacy greater with higher CD4 (>200), undetectable VL. Defer vaccination in pts about to start ART.

Other Health  Maintenance

  • Breast exam. Mammogram in women over 40 (every 1-2 yrs; annual after age 50)
  • Colonoscopy: over 50 (repeat in 10 years if negative)
  • PSA: High false+, not routine. Age 50-70 most likely to benefit, particularly if African-American or 1st degree relative with prostate cancer, but risk of false + should be first discussed
  • Bone density: women > 60, or if high-risk for early osteopenia in women, or high-risk (early menopause, steroid use, hypogonadism).
  • ECG: if clinically indicated. Not routine.
  • PFTs: if clinically indicated. Not routine.

Counselling

  • ART: Preparation for life-long treatment, adherence, adverse effects, readiness before starting
  • Sexual practices, barrier and contraceptive use, pregnancy plans
  • Substance and alcohol use and treatment
  • Smoking cessation, diet, exercise, dietary supplements
  • Social support, housing, living assistance

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Last updated: November 17, 2011