Initial Evaluation

Richard D. Moore, M.D. , Christopher J. Hoffmann, M.D., M.P.H.

CLINICAL RECOMMENDATION

Medical History

  • Establish rapport: HIV care is life-long, and the initial evaluation is to focus on understanding and addressing a patient’s concerns and stated immediate needs. This time can be used to assess the patient’s HIV knowledge, their primary questions related to HIV, and information to discuss or reinforce. Not everything needs to be covered on the first visit of the longitudinal care journey.
  • HPI: include date of Dx, date of infection if known, nadir CD4, peak VL, OIs and Sxs (stage HIV)
  • Gender: gender identity, gender affirmation including hormones and surgical hx or plans
  • PMH:
    • Include prior TB or exposure, PPD/IGRA history
    • Chicken pox or shingles
    • Kidney disease
    • Liver disease
    • Cardiovascular disease
    • Mental health (e.g. depression screening with PHQ-2 or PHQ-9)
  • Meds: ART history (if any) and lapses in ART, other medications, OTCs, hormone use, dietary supplements, methadone
  • Vaccinations: History of Td or Tdap, pneumococcal, hepatitis B and A, flu (seasonal), HPV, and varicella and herpes zoster vaccines
  • Sexual history: partners (men, women, both), practices, barrier use, HIV status of partner(s) including viral load, STDs, use of chem-sex (usually methamphetamine), anonymous sex, etc.
  • 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.
  • Reproduction plans: men and women
  • Substance use: street, prescribed, recreational, needle-sharing, chem-sex, alcohol use (with CAGE or AUDIT), smoking
  • Social:
    • How the patient is adapting to the diagnosis; level of internalized stigma (shame)
    • Partner(s) and nature of relationship
    • Disclosure to family or friends
    • Family/partner violence
    • HIV status of partner and children (if any)
    • Social support
    • Diet, exercise
    • Education
    • Employment
    • Health insurance and health care access

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. anal dysplasia (anal pap if increased risk - anal sex).
  • Eyes: retinal exam if CD4 < 50.
  • Oral cavity: thrush, oral lesions (syphilic chancers, HPV-associated lesions)
  • 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

Laboratory Assessment

  • 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 nephropathy or other early renal disease (e.g. HTN, DM).
  • C. trachomatis and N. gonorrhea by NAAT (all sexually active pts or w/ Sx) preferred with sites based on exposure (e.g., 3-site testing: urine, rectal swab, oropharyngeal swab)
  • HIV genotype (if VL >500-1000). Indicated regardless of need for ART, as mutations may disappear. RTI and PI only. Routine IN 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-Varicella IgG: in pts with no history of chicken pox or shingles
  • Serum cryptococcal antigen: if CD4 < 100
  • Serum toxoplasma antibody: if CD4 < 200
  • TB infection screening: IGRA or TST
  • Pregnancy test: missed menses
  • Tropism assay: if considering MVC use

Procedures

  • Ophthalmologic fundoscopic exam: if CD4 < 50 or with visual Sx
  • Anal Pap with cytology and high risk HPV typing and digital anorectal exam: 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 HSIL; consider HRA for LSIL or ASC-US with HPV type 16 or 18. If HRA not available, pap testing not recommended.
  • Vaccinations:
    • COVID-19 vaccine: standard vaccination schedule with updated boosters
    • Td every 10 years, with TdaP given once
    • Pneumococcal vaccination: PCV21 (Prevnar 21), 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: if non-immune. Vaccine efficacy greater with higher CD4 (>200), undetectable VL. Defer vaccination in pts about to start ART.
    • Hepatitis A: If non-immune
    • MMR: For patients without evidence of measles, mumps, or rubella immunity and with CD4 >200
    • Shingles (Shingrix): if >50 years and evidence of prior VZV infection (either prior chickenpox or shingles or positive varicella IgG).
    • Varicella vaccine (Varivax): if not already immune and CD4 ≥200, born after 1979 and no immunity
    • HPV: males and females age 9-45. Gardasil 9.
    • Meningococcal: MenACWY. Recommended for all patients with HIV (Menactra, Menveo, or MenQuadfi).
    • Mpox: individuals who are at increased risk (multiple often casual sexual partners, often MSM, is the biggest risk) for Mpox or who have been exposed to Mpox in the past 14 days. Only use the JYNNEOS vaccine.

Other Health Maintenance

  • Abdominal aortic aneurysm: cis-gender men and transgender women aged 65-75 with a history of smoking.
  • Breast cancer: ACA: Mammogram in women and transgender men 40-74 yrs every 2 yrs
  • Cervical cancer (if cervix is present): begin within 2 yrs of onset of sexual activity or by age 21 repeat at 6 mos, then every 3 years if negative. Refer for colposcopy if abnormal.
  • Colonoscopy: >45 (repeat in 10 years if negative, or more frequently depending on pathology of polyps)
  • Cardiovascular disease: estimate 10-yr ASCVD risk. Use to guide risk factor modification.
  • Prostate cancer (if prostate is present): 55-69 years (can start earlier if family history.
  • Bone density (DXA): baseline screening for men >50 and post-menopausal women, or high-risk (early menopause, steroid use, hypogonadism).
  • Lung cancer: use low radiation screening lung CT aged 55-74, current smoker or < 15 yrs since quit, >30 pack-yrs

Counseling

  • ART: Rapid ART initiation (within 7 days of diagnosis) if not previously on ART. Preparation for life-long treatment, adherence, adverse effects, readiness before starting
  • Sexual practices, promote sexual health, ideal sex life, harm reduction as needed, discuss U=U, barrier and contraceptive use, pregnancy plans
  • Substance and alcohol use and treatment
  • Cardiovascular risk modification: Smoking cessation, diet, exercise, dietary supplements, statin therapy initiation (for adults living with HIV aged 40+)
  • Social support, housing, living assistance

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Last updated: January 10, 2025