INITIAL EVALUATION OF HIV-INFECTED PATIENTS

Initial evaluation of the patient with HIV includes an assessment of the stage of HIV disease, risk for coinfections, identification of comorbidities associated with HIV infection or treatment, and the selection of an antiretroviral regimen.

Medical History

A comprehensive medical history is obtained on initial visit with a patient who has been diagnosed with HIV and includes:

HISTORY OF HIV INFECTION

  • Risk behaviors for HIV infection and approximate date of onset
  • History of opportunistic infections
  • Knowledge of initial and recent CD4 T cell counts and viral load (RNA) results
  • Medical records obtained to confirm treatment history and viral load responses, side effects, and/or long-term toxicities

GENERAL HISTORY

  • Coinfections with hepatitis B, hepatitis C, or tuberculosis
  • History of cardiovascular risk factors or diseases:
    • Hypertension
    • Diabetes mellitus
    • Dyslipidemia
  • History of sexually transmitted infections
  • Gynecologic and obstetrical history
  • Malignancies, including history of smoking, family history of cancer
  • Psychiatric history, particularly depression
  • History of trauma, sexual abuse, physical abuse, or other forms of intimate partner violence
  • Other comorbidities, such as:
    • Chronic renal insufficiency
    • Peripheral neuropathy
    • Metabolic bone disease
  • Medications and allergies:
    • Antiretroviral drug history
    • History of medication adherence
  • Use of complementary, alternative, and over-the-counter therapies
  • Immunization history, including dates:
    • Pneumococcal
    • Meningococcal
    • HPV
    • Tetanus
    • Hepatitis A and B
    • COVID-19
  • Social history:
    • Ongoing risk factors for HIV transmission
    • Other exposures that may increase risk of other infections or comorbidities
    • Substance use
    • Employment, housing, and travel history
    • Sexual history, past and current:
      • Condom use
      • Contraceptive use
      • Gender identity
  • Family medical history, including:
    • Coronary artery disease
    • Diabetes mellitus
    • Dyslipidemia
    • Malignancies

REVIEW OF SYSTEMS

  • Constitutional symptoms, such as:
    • Fevers
    • Night sweats
    • Weight loss
    • Localized complaints
  • HIV-related common signs and symptoms:
    • New visual floaters
    • Change in vision
    • Candidiasis (thrush)
    • Dysphagia (difficulty swallowing)
    • Odynophagia (painful swallowing)
    • Cough
    • Shortness of breath
    • Diarrhea
    • Skin rash
    • Headache
    • Inability to concentrate
    • Muscle weakness or paresthesia
      (Libman & Pollack, 2023)

Physical Examination

A complete physical examination is carried out on initial evaluation, including an assessment for findings that are common in a patient with HIV, particularly those with advanced immunosuppression.

  • Height and weight
  • Skin:
    • Seborrheic dermatitis
    • Eosinophilic folliculitis
    • Psoriasis
    • Dermatophytosis (superficial fungal disease)
    • Molluscum contagiosum (poxvirus skin infection)
    • Herpes simplex
    • Herpes zoster (shingles)
    • Kaposi’s sarcoma
  • Body fat and body fat distribution:
    • Lipodystrophy
  • Oral mucosa:
    • Candidiasis
    • Oral hair leukoplakia
    • Herpetiform lesions (canker sores)
    • Herpes simplex (cold sores)
  • Anogenital, for evidence of STIs and vaginitis
  • Neurological exam:
    • Peripheral neuropathy
    • Asymptomatic muscle weakness
    • Other abnormalities
  • Assessment of cognitive function
  • Generalized lymphadenopathy
    (Libman & Pollack, 2023)

Laboratory Testing

Initial laboratory testing includes an assessment of the patient’s HIV status and baseline testing for organ function and potential coinfections.

HIV-specific initial laboratory testing includes:

  • HIV serology to establish diagnosis
  • CD4 T cell count and percentage
  • Baseline viral load (RNA)
  • Drug resistance testing

General blood and urine testing should include:

  • Complete blood count and differential
  • Renal function tests
  • Hepatic function tests
  • Glucose and lipid profile
  • Urine pregnancy test

Screening for coinfections includes:

  • Viral hepatitis A, B, and C
  • Tuberculosis PPD testing or interferon gamma testing with follow-up chest X-ray for positive screening results
  • STDs:
    • Syphilis
    • Gonorrhea
    • Chlamydia
    • Trichomoniasis in women
  • Screening for certain infections as needed, including:
    • Cryptococcal antigen
    • Toxoplasma IgB antibody titer
    • Immunity testing for measles, mumps, and rubella
  • PAP screening for HIV-associated neoplasia:
    • Cervical cancer
    • Anal cancer in both men and women
  • Bone marrow density testing for postmenopausal women and men ages 50 years and older
  • G6PD screening for glucose-6-phosphate dehydrogenase deficiency for patients of African, Asian, or Mediterranean descent (as certain drugs used in treatments of patients with HIV can precipitate hemolysis in those with deficiency)

Additional testing is done to evaluate for potential adverse reactions and drug activity prior to selection of appropriate antiretroviral agents (Libman & Pollack, 2023).