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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
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