Initial evaluation of the HIV-infected adult
- Howard Libman, MD
Howard Libman, MD
- Professor of Medicine
- Harvard Medical School
- Todd M Pollack, MD
Todd M Pollack, MD
- Instructor in Medicine, Part-time
- Harvard Medical School
The initial evaluation of the HIV-infected adult is comprehensive and may take place over several visits. Its goals are to assess the stage of HIV disease, determine the risk for other infections, identify co-morbidities that are associated with HIV infection, and evaluate for the initiation and selection of antiretroviral therapy. In addition, the initial evaluation is an important time to establish the patient-practitioner relationship and educate the patient about the natural history and management of HIV infection.
This topic discusses the elements of the initial evaluation of patients with HIV infection. Primary care of the HIV-infected patient is discussed elsewhere. (See "Primary care of the HIV-infected adult".)
In the United States, the HIV Medicine Association of the Infectious Diseases Society of America has published guidelines on the primary care of HIV-infected individuals, which were last updated in 2013 . The recommendations discussed in this topic are generally consistent with these guidelines.
ESTABLISHING THE DIAGNOSIS
Patients with a prior history of HIV infection — In patients who present at their initial visit with a prior history of HIV infection, efforts should be made to obtain documentation of HIV antibody or HIV RNA testing in the past. If these records are not available, repeat HIV antibody testing should be performed to confirm the diagnosis since cases of factitious HIV infection have been reported . (See 'HIV serology' below.)
- Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 58:e1.
- European AIDS Clinical Society Guidelines. Updated yearly. http://www.eacsociety.org/Guidelines.aspx.
- Craven DE, Steger KA, La Chapelle R, Allen DM. Factitious HIV infection: the importance of documenting infection. Ann Intern Med 1994; 121:763.
- Graham CS, Baden LR, Yu E, et al. Influence of human immunodeficiency virus infection on the course of hepatitis C virus infection: a meta-analysis. Clin Infect Dis 2001; 33:562.
- Jakobsen MR, Arildsen H, Krarup HB, et al. Entecavir therapy induces de novo HIV reverse-transcriptase M184V mutation in an antiretroviral therapy-naive patient. Clin Infect Dis 2008; 46:e88.
- Taylor LE, DeLong AK, Maynard MA, et al. Acute hepatitis C virus in an HIV clinic: a screening strategy, risk factors, and perception of risk. AIDS Patient Care STDS 2011; 25:571.
- Horsburgh CR Jr. Priorities for the treatment of latent tuberculosis infection in the United States. N Engl J Med 2004; 350:2060.
- Yang Z, Kong Y, Wilson F, et al. Identification of risk factors for extrapulmonary tuberculosis. Clin Infect Dis 2004; 38:199.
- Chesson HW, Heffelfinger JD, Voigt RF, Collins D. Estimates of primary and secondary syphilis rates in persons with HIV in the United States, 2002. Sex Transm Dis 2005; 32:265.
- Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001; 58:721.
- Lawrence ST, Willig JH, Crane HM, et al. Routine, self-administered, touch-screen, computer-based suicidal ideation assessment linked to automated response team notification in an HIV primary care setting. Clin Infect Dis 2010; 50:1165.
- Hoover KW, Butler M, Workowski KA, et al. Low rates of hepatitis screening and vaccination of HIV-infected MSM in HIV clinics. Sex Transm Dis 2012; 39:349.
- Tedaldi EM, Baker RK, Moorman AC, et al. Hepatitis A and B vaccination practices for ambulatory patients infected with HIV. Clin Infect Dis 2004; 38:1478.
- Kirk GD, Merlo C, O' Driscoll P, et al. HIV infection is associated with an increased risk for lung cancer, independent of smoking. Clin Infect Dis 2007; 45:103.
- Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 2013; 56:727.
- Shoptaw S, Reback CJ, Frosch DL, Rawson RA. Stimulant abuse treatment as HIV prevention. J Addict Dis 1998; 17:19.
- Hulgan T, Raffanti S, Kheshti A, et al. CD4 lymphocyte percentage predicts disease progression in HIV-infected patients initiating highly active antiretroviral therapy with CD4 lymphocyte counts >350 lymphocytes/mm3. J Infect Dis 2005; 192:950.
- Gebo KA, Gallant JE, Keruly JC, Moore RD. Absolute CD4 vs. CD4 percentage for predicting the risk of opportunistic illness in HIV infection. J Acquir Immune Defic Syndr 2004; 36:1028.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf (Accessed on April 08, 2015).
- Kim D, Ziebell R, Saduvala N, et al. Trend in transmitted HIV-1 ARV drug resistance-associated mutations: 10 HIV surveillance areas, US, 2007-2010. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 149.
- Freedberg KA, Malabanan A, Samet JH, Libman H. Initial assessment of patients infected with human immunodeficiency virus: the yield and cost of laboratory testing. J Acquir Immune Defic Syndr 1994; 7:1134.
- Lucas GM, Ross MJ, Stock PG, et al. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96.
- Wang JY, Hsueh PR, Wang SK, et al. Disseminated tuberculosis: a 10-year experience in a medical center. Medicine (Baltimore) 2007; 86:39.
- Laine L, Politoske EJ, Gill P. Protein-losing enteropathy in acquired immunodeficiency syndrome due to intestinal Kaposi's sarcoma. Arch Intern Med 1987; 147:1174.
- Pass RF. Epidemiology and transmission of cytomegalovirus. J Infect Dis 1985; 152:243.
- Collier AC, Meyers JD, Corey L, et al. Cytomegalovirus infection in homosexual men. Relationship to sexual practices, antibody to human immunodeficiency virus, and cell-mediated immunity. Am J Med 1987; 82:593.
- Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin Infect Dis 1992; 15:211.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on October 20, 2015).
- Piketty C, Selinger-Leneman H, Grabar S, et al. Marked increase in the incidence of invasive anal cancer among HIV-infected patients despite treatment with combination antiretroviral therapy. AIDS 2008; 22:1203.
- Williams AB, Darragh TM, Vranizan K, et al. Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women. Obstet Gynecol 1994; 83:205.
- Günthard HF, Aberg JA, Eron JJ, et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:410.
- ESTABLISHING THE DIAGNOSIS
- Patients with a prior history of HIV infection
- Patients with suspected HIV infection
- History of infection
- Past medical history
- Medications and allergies
- Immunization history
- Social history
- Family history
- Review of systems
- PHYSICAL EXAMINATION
- INITIAL LABORATORY TESTING
- HIV-related testing
- - HIV serology
- - CD4 cell count and percentage
- - Viral load
- - Resistance testing
- - Additional tests to inform ART selection
- General blood and urine testing
- - Complete blood count
- - Renal function
- - Hepatic function
- - Glucose and lipid profile
- Screening for co-infections
- - Viral hepatitis
- - Tuberculosis
- - Sexually transmitted infections
- - CMV and VZV
- - Toxoplasma
- Screening for HPV-associated neoplasia
- - Cervical cancer
- - Anal cancer
- Select testing
- - G6PD deficiency
- - Bone mineral density testing
- EVALUATION FOR ANTIRETROVIRAL THERAPY
- PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS
- RISK REDUCTION COUNSELING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS