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- 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), other medications, OTCs, dietary supplements, methadone
- Vaccinations: History of Td or Tdap, pneumococcal, hepatitis B and A, flu (seasonal), HPV, and varicella and herpes zoster vaccines
- Substance use: street, prescribed, recreational, needle-sharing, alcohol use (with CAGE or AUDIT), smoking
- Sexual history: practices, barrier use, HIV status of partner(s) including viral load, 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, cancer, diabetes, hyperlipidemia
- Women: menstrual history, contraception, infertility, pregnancy history, childbearing plans , osteoporosis Dx and treatment.
- 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 (dysplasia), especially in MSM.
- Skin: KS, fungal, folliculitis, prurigo nodularis
- Body habitus: fat accumulation, lipoatrophy
- Oropharynx: candidiasis, OHL, KS, aphthous ulcers, periodontal disease.
- Lymphadenopathy: localized requires evaluation; generalized common in HIV+
- Neurologic: cognitive dysfunction, neuropathy, focal neurologic findings
- HIV serology: if lab confirmation (serology, elevated VL) not available
- CD4 count: to stage HIV and determine need for OI prophylaxis, urgency of ART. Every 3-6 mos if not on ART
- VL (plasma HIV RNA): stage HIV. If initiation of ART deferred, repeat before initiation. Repeat testing optional in patients not initiating ART.
- Syphilis testing: repeat annually or more often in pts at high risk
- Chemistries: include AST, ALT, BUN, creatinine, bilirubin, alk phos, albumin, electrolytes; calculate estimated GFR (eGFR) using creatinine
- CBC with differential
- Fasting blood glucose and/or HgA1C
- Fasting lipid profile (TG, TC, HDL, LDL): Baseline and after initiating ART
- Urinalysis: Proteinuria may indicate HIV-associated nephropathyor other early renal disease (e.g. HTN, DM).
- C. trachomatis and N. gonorrhea by NAAT (all sexually active pts or w/ Sx) prefered with sites based on exposure (eg, urine, urethral, vaginal, cervical, rectal, oropharyngeal)
- HIV genotype (if VL >500-1000). Indicated regardless of need for ART, as mutations may disappear. RTI and PI only. Routine integrase genotype not recommended unless transmitted resistance is a concern.
- G6PD: consider in pts at risk (African or Mediterranean descent), especially before use of dapsone, primaquine, sulfonamides
- Hepatitis serologies:
- Hepatitis A: total anti-HAV Ab
- Hepatitis B: HBsAg, HBsAb, HBcAb. HBeAg/HBeAb and HBV DNA if HBsAg+; HBV DNA if HBcAb+/HBsAb-/HBsAg- or if elevated LFTs
- Hepatitis C: anti-HCV. HCV PCR if anti-HCV+ or negative with risk factors or elevated LFTs.
- anti-ToxoplasmaIgG: evaluate for latent Toxoplasma infection. Counsel seronegative pts on avoiding exposureLab assessment
- anti-CMV IgG: 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
- Testosterone level (AM free level preferred): in men with clinical indication (weight loss, fatigue, loss of libido, erectile dysfunction, depression)
- Pregnancy test: missed menses
- PSA: Routine screening not recommended b/o high false-positive rate, and discussion recommended regarding risk and benefits. (ACA, USPSTF, AUA); AUA; age 40-54 (those at high risk), 55-69 (shared decision based on risk), no screening after age 70 or life-expectancy < 10-15 yrs; ACA: 40-44 (if highest risk, >1 first-degree relative at early age [< 65] with prostate cancer), 45-50 (if high risk (African-American or first-degree relative with ca at early age), >50 yrs (if average risk and life-exp >10 yrs); USPSTF: screening not recommended at any age.
- HLA B*5701: at baseline, or if considering ABC use
- Tropism assay: if considering MVC use
- Ophthalmologic fundoscopic exam: if CD4 < 50 or with visual Sx
- Chest x-ray: If PPD+ or IGRA+ or if clinically indicated. Not routine.
- Cervical Pap: repeat at 6 mos, then annually if negative. Refer for colposcopy if abnormal. Trichomoniasis screening in all women.
- Anal Pap: consider, especially in MSM or women with history of anal intercourse, cervical dysplasia, or HPV infection. Repeat every 1-3 years. Refer for high resolution anoscopy (HRA) if abnormal. If HRA not available, Pap testing not recommended.
- PPD or IGRA: Baseline, and repeat annually in pts at risk for TV; repeat after immune reconstitution on ART if initial PPD/IGRA negative with low CD4.
- Td every 10 years, with TdaP given once
- Pneumococcal vaccination: PCV13 (Prevnar 13), then PPV23 (Pneumovax) 8 wks later. If PPV23 already administered, give PCV13 one year after last PPV23. Repeat PPV23 once at least 5 years after first dose.
- Influenza: annual in the Fall. Avoid live nasal vaccine
- Hepatitis B and A: if non-immune. Vaccine efficacy greater with higher CD4 (>200), undetectable VL. Defer vaccination in pts about to start ART.
- Shingles (Zostavax): consider if >60 years, CD4>200.
- Varicella vaccine (Varivax): if not already immune and CD4 ≥200, born after 1979 and no immunity
- HPV: males and females age 9-26. Gardasil recommended, but Gardasil 9 preferred.
Other Health Maintenance
- Breast: ACA: Mammogram in women >40 (annual); USPHSTF: every 2 yrs for women 50-74, discussion of risk/benefits for 40-50.
- Colonoscopy: >50 (repeat in 10 years if negative, or more frequently depending on pathology of polyps)
- PSA: see above. High false+, not routine.
- Bone density (DXA): men >50 and post-menopausal women, or high-risk (early menopause, steroid use, hypogonadism).
- ECG: if clinically indicated. Not routine.
- PFTs: if clinically indicated. Not routine.
- Low radiation screening lung CT: age 55-74, current smoker or < 15 yrs since quit, >30 pack-yrs, no lung history of lung cancer
- 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