Johns Hopkins HIV Guide
Initial Evaluation
Initial Evaluation is a topic covered in the Johns Hopkins HIV Guide.
To view the entire topic, please log in or purchase a subscription.
Official website of the Johns Hopkins Antibiotic (ABX), HIV, Diabetes, and Psychiatry Guides, powered by Unbound Medicine. Johns Hopkins Guide App for iOS, iPhone, iPad, and Android included. Explore these free sample topics:
-- The first section of this topic is shown below --
CLINICAL RECOMMENDATION
Medical History
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), 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.
Physical Exam
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 (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
Laboratory Assessment
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 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
Procedures
Procedures
- 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.
- Vaccinations:
- 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
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
Counselling
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
-- To view the remaining sections of this topic, please log in or purchase a subscription --
CLINICAL RECOMMENDATION
Medical History
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), 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.
Physical Exam
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 (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
Laboratory Assessment
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 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
Procedures
Procedures
- 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.
- Vaccinations:
- 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
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
Counselling
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
There's more to see -- the rest of this topic is available only to subscribers.
Last updated: November 9, 2016
Citation
Moore, Richard D. "Initial Evaluation." Johns Hopkins HIV Guide, 2016. Johns Hopkins Guides, www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545103/all/Initial_Evaluation.
Moore RD. Initial Evaluation. Johns Hopkins HIV Guide. 2016. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545103/all/Initial_Evaluation. Accessed March 22, 2023.
Moore, R. D. (2016). Initial Evaluation. In Johns Hopkins HIV Guide https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545103/all/Initial_Evaluation
Moore RD. Initial Evaluation [Internet]. In: Johns Hopkins HIV Guide. ; 2016. [cited 2023 March 22]. Available from: https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545103/all/Initial_Evaluation.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - Initial Evaluation
ID - 545103
A1 - Moore,Richard,M.D.
Y1 - 2016/11/09/
BT - Johns Hopkins HIV Guide
UR - https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545103/all/Initial_Evaluation
DB - Johns Hopkins Guides
DP - Unbound Medicine
ER -
