Transcript HIV-1st visit - Dr P Willemot

First Cont(r)act
The Initial Evaluation of
the HIV infected patient
Patrick Willemot
2010 September 23
Overview
 History
 General Health
 Past Histories
 Opportunistic Infections
 Physical Examination
 Investigations
 Health Maintenance
#1: How did they
come to see you?
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Referred by MD?
Self-obtained test?
Referred by gov’t or insurance?
Contact tracing?
Transfer of care? (not discussed this time)
#2: Confirm HIV Diagnosis
 HIV Ab ELISA
 Confirmatory Western blot
 Viral load
 p24 antigen - not recommended
Remember to discuss: 4 points
 1. HIV biology
 *transmission (must get into the nitty-gritty)
 re-infection risk among seroconcordant partners
 mechanism of ARVs and resistance
Remember to discuss: 4 points
 2. treatability but incurability
 try to normalise it a bit: “like diabetes…”
NEJM 1998 Mar 26; 338 (13): 853-860.
AIDS 1999 Oct 1; 13 (14): 1933-1942.
Remember to discuss: 4 points
 3. good prognosis with treatment
 HIV ≠ AIDS (usefulness of “AIDS” label
debatable)
 4. women can bear children safely
 transmission reduced from 25-30% to <1%
General Health
 Present complaints
 Functional Status
 Past & present risk behaviours
 What’s their risk of co-infection?
 What’s their risk of re-infection?
 What’s their risk of infecting others?
NB: remember to use value-neutral language
Past History
 A) HIV-associated
 OIs, neoplasia
 B) Non-HIV associated
 C) STDs
 D) ARV exposure history
 with serial CD4, VL, resistance profiles
 E) Immunizations
 pneumococcal, influenza, viral hep, general
Risk for Opportunistic Infections
 Occupational history
 Travel history
 southwest US states, SE Asia, …
 Pets
Physical Examination
 Usual
 Height & Weight
 Dermatologic
 Rectogenital, including swabs for SILs
 Assessment of cognitive status (MMSE/MoCA)
Investigations
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CBC, ’lytes, hepatic, renal, pancreatic
CD4, VL, resistance profile
VDRL, HBV, HCV, Toxoplasma, CMV
PPD & CXR
G6PD, HLA-B*5701
urinalysis, ECG
(stool O+P; strongyloides serology)
cervical smear
Health Maintenance
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partner notification
safe(r) sex practices
drug rehabilitation/safe(r) use
vaccinations (HAV, HBV, influenza,
pneumococcal, general)
 age-appropriate screening/prevention
Decision to start HAART
 Usually not to be taken at first visit…
 Need a bit more data
 CD4, VL and resistance profile
 decision regarding OI prophylaxis
 willingness to take medications every day…
Summary
 Quite a few data points to cover
 Your agenda and their agenda may be
different - take your time
 Remember to address what they’re worried
about
 will I die
 can you help me
 can I have kids?
 It may take more than one visit!
 Questions?
 Comments?
 Concerns?