Initial Evaluation of the HIV+ Patient

Mitchell D. Feldman, MDProfessor

UCSF

Case Dr W is seeing Ms T, a 35 year old woman, for a routine

examination and for renewal of her medications. She reports being well but did have an episode of HSV that was treated last month. She is now better. She is currently married and monogamous. On further questioning, she reports a history of 5 sexual partners including a short-term relationship with a man who had used intravenous drugs. She has never been HIV tested. Dr W notes that the patients history of HSV prior to age 50 may be an early manifestation of immunosuppression. He decides to offer her HIV screening.

Who should be screened for HIV?

Everyone? Many patients remain undiagnosed for years. These undiagnosed patients may infect others

and may develop illnesses that could have been prevented.

Many patients are unaware that they are at risk. Patients who ask for test should be screened.

HIV Risk Factors High-Risk Behaviors or exposures

MSM sexual partner of IDU Multiple partners Sex workers History of STI, IDU Hep B or C Incarceration History of transfusion

Clues to HIV+

Clinical Signs/Clues Active TB HZV in healthy person < 50 History of:

Hep B or C, thrush, diffuse LAN, weight loss, cervical cancer, unexplained anemia, leukopenia or

thrombocytopenia

What is this?

Primary HIV Infection

Primary HIV Infection Occurs in 80%-90% of infected patients. Exposure to onset usually 2-4 weeks. Typical symptoms: fever, LAN,

pharyngitis, rash, myalgias. Some have headache, aseptic meningitis, peripheral neuropathy, facial palsy.

Lymphopenia followed by lymphocytosis, transient decrease in CD4.

Discussing a positive HIV result with the patient Be prepared! Be sensitive to stigma--this may be more

difficult for patients than other bad news. Assess patients knowledge--and educate

the patient about HIV transmission and prevention.

“Prevention for Positives”

Initial History Common HIV related symptoms:

Fevers, sweats, weight loss, diarrhea, rash HIV risk behaviors

Inform current sexual partners of diagnosis Risk reduction

Travel history, immunizations, pets, health-related behaviors

Depression Assess adherence

Physical Examination Complete baseline physical examination Skin

Seb. Derm, KS, folliculitis, fungal, warts, xerosis, molloscum

Oropharynx Candidiasis, Oral hairy leukoplakia,periodontal disease

Hairy Leukoplakia

Candida Glossitis

Kaposis Sarcoma Maxillary Palate

Physical Examination

Persistent generalized lymphadenopathy Rubbery, 1cm or less, not tender, nonspecific

hyperplasia on biopsy

Gynecologic exam/PAP q 6 months Consider anal PAP Neurologic exam

Cognitive function

Laboratory Studies CBC and differential

Mild normocytic anemia, leukopenia

Platelets Common manifestation of HIV; often improves

spontaneously as the disease progresses; bleeding rare unless plats below 25,000

Creatinine, LFT’s, lipids, glucose Viral Hepatitis Resistance Testing

Laboratory Studies CMV serologies

Very high sero-prevalence among HIV+ Routine prophylaxis not recommended

Toxoplasma IgG 20%-50% of HIV/toxo + will develop encephalitis Prophylaxis with TMP-SMX recommended when

CD4 below 100/mm

CD4, Viral load, HIV resistance resting

Laboratory Studies

Syphilis Repeat syphilis serology yearly LP for pts with latent syphilis or with neurological

signs PPD yearly

TB prophylaxis recommended for all HIV-infected patients with:

Positive PPD (5mm of induration) History of PPD+ Close contact of patient with active TB

Laboratory Studies

Other tests to consider include: CXR Testosterone Anti-varicella IgG Anti-HAV

For asymptomatic persons

Prophylaxis of OI’s PCP

CD4 < 200 (or <14%) History of PCP,thrush, or constitutional

symptoms suggestive of advanced immunodeficiency

TMP-SMX, dapsone, aero-pentamadine, atovaquone

Prophylaxis of OI’s MAC

CD4 < 50 Clarithromycin 500mg bid Azithromycin 1200mg weekly Alternative is Rifabutin 300mg qd

Fungal-- prophylaxis not recommended

Vaccines Give vaccines as early as possible For more advanced patients, defer

vaccination until after HAART is initiated Live virus or bacteria vaccines should not

be given (BCG, oral polio, oral typhoid, varicella-zoster, yellow fever)

Vaccines Influenza

Transient rise in VL Defer in patients with advanced disease

Hepatitis Hep B--first screen for past infection Hep A--especially for travel

Tetanus-Diphtheria Same recs as for non HIV

Special Issues Proxy for healthcare decisions Wishes regarding terminal care

Living will, DPA for health care

Reporting requirements Community support Social isolation Build the doctor-patient relationship