Assessment of an HIV positive patient, Initial assessment, Lymph glands, visual acuity, visual fields, pupil size, pupil reactivity, and extra-ocular movements, anal/rectal discharge, condylomata, ulcers, prostate assessment, and tests for STIs as appropriate, seborrhoeic dermatitis, fungal nail infection, warts, Kaposi's sarcoma, molluscum contagiosum, and abnormal pigmentation,

Assessment of an HIV positive patient

Initial assessment

Objectives

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  Reinforce the patient's understanding of HIV infection and how to avoid further transmission.
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  Identify medical, socio-economic, and legal problems.
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  Establish stage of disease.
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  Establish a rapport with patient (essential to ensure efficient follow up).

Full history, medical examination, and baseline investigations to plan future management and drug therapy. Further tests depend on the circumstances and stage of disease.

History

• Sexual history including, sexual partners/practices, condom use, and contraception.
• Current and previous medical (especially, tuberculosis, STIs, or hepatitis), surgical, gynaecological, and obstetric history.
• Current medication and allergies.
• Drug, substance, and alcohol use.

Clinical examination

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  General: weight, temperature, pulse, BP, respiratory rate, pallor, and jaundice.
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  Lymph glands: lymphadenopathy site, size, symmetry, tenderness, and consistency.
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  Mouth and throat: gum and tooth disease, oral ulceration, hairy leukoplakia, candidiasis, and enlarged pharyngeal lymphoid tissue.
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  Cardiovascular: routine examination.
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  Respiratory: routine examination.
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  Abdomen: routine examination.
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  Neurological: routine examination. Specifically assess eyes checking visual acuity, visual fields, pupil size, pupil reactivity, and extra-ocular movements. Examine retinae ideally with pupils dilated.
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  Genital/pelvic examination: discharges, ulcers, condylomata, testicular enlargement or atrophy, cervical abnormalities, pelvic masses, and STI screening.
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  Cervical cytology: annual review with close follow up if abnormal.
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  Perianal and rectal examination: anal/rectal discharge, condylomata, ulcers, prostate assessment, and tests for STIs as appropriate.
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  Skin: general skin examination specifically checking for seborrhoeic dermatitis, fungal nail infection, warts, Kaposi's sarcoma, molluscum contagiosum, and abnormal pigmentation.

Laboratory investigations

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  Full blood count, urea, electrolytes and liver function tests, glucose, triglycerides, and cholesterol.
• Serological tests: hepatitis A, hepatitis B (surface antigen and core antibody), hepatitis C, cytomegalovirus (CMV) IgG, toxoplasma, varicella zoster virus (VZV) IgG and syphilis.
• Viral load (VL): informs on likely rate of disease progression and monitors response to therapy.
• Undetectable VL indicates level <25/50copies/mL (depending upon test used).
• <5000copies/mL generally suggests low rate of progression in the coming 5 years.
• >55,000copies/mL are associated with ↑ rate of progression
• CD4 count: usually measured as part of lymphocyte subsets.
• Main indicator of risk of opportunistic infection and possible need for prophylactic treatment in the asymptomatic patient.
• Individual results may be influenced by other factors, e.g. intercurrent infections.
• Repeat if unexpectedly low or high count.
• Trend is more useful than single readings.
• Plasma samples for viral resistance testing.

Further investigations and follow-up

• Estimate stage of HIV infection from initial assessment and baseline investigations.
• Assess disease progression: HIV-related infections and malignancies, response to therapy and signs of drug toxicity.
• Monitor VL and CD4 count at regular intervals, frequency depends on the patient's clinical status. Asymptomatic patients with stable disease may have their VL and CD₄ count measured every 3 to 6 months but shorter intervals may be necessary for those with more advanced disease.

Drug prophylaxis

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  Pneumocystis jiroveci (carinii) pneumonia (PCP): when CD4 count <200cells/µL, first choice is trimethoprim/sulfamethoxazole (co-trimoxazole) orally 960mg 3 times a week. If allergic consider desensitization (see Table 38.1). Alternatives are: dapsone 50 to 100mg daily, dapsone 50mg plus pyrimethamine 50mg 3 times a week, atovaquone 750mg 3 times a week or nebulized pentamidine 300mg once a month.
  Azithromycin 500mg 3 times a week may be effective as primary prophylaxis.
• Tuberculosis (TB): prior BCG vaccination provides unreliable protection. A negative tuberculin test may be due to anergy and does not exclude TB. Chemoprophylaxis is recommended for close contacts of smear positive pulmonary TB. 6 months of isoniazid 300mg daily or 3 months of isoniazid 300mg daily plus rifampicin 600mg daily are effective.
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  Toxoplasmosis: if CD4 count <100cells/µL and toxoplasma IgG positive. Co-trimoxazole and maloprim (as for PCP prophylaxis).
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  VZV: varicella zoster immunoglobulin (5 vials IM) if seronegative for VZV antibodies within 72 hrs of significant exposure.
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  Mycobacterium avium complex prophylaxis may be considered with CD4 counts less than 50 cells/µL.

Vaccination

Inactivated rather than live vaccines should be used (e.g. polio). If travelling abroad additional vaccination may be required. Those immuno- deficient may not mount a good response to vaccination. Vaccination can be delayed until immune reconstitution ensues although unnecessary delay should be avoided if there is a specific infection risk.

• Pneumovax: can be given to all patients.
•  Hepatitis A: if immunonegative.
• Hepatitis B: if immunonegative.
• Influenza vaccination: controversial, but safer if given to those whose HIV infection is suppressed by antiviral therapy.