Initial Evaluation

Richard D. Moore, M.D.

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), 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 

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

  • 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

  • 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

  • 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 9, 2016