First Cont(r)act The Initial Evaluation of the HIV infected patient Patrick Willemot 2010 September 23 The Initial Evaluation of the HIV infected patient.

First Cont(r)actFirst Cont(r)act

The Initial Evaluation of

the HIV infected patient

Patrick Willemot

2010 September 23

The Initial Evaluation of

the HIV infected patient

Patrick Willemot

2010 September 23

OverviewOverview History

General Health Past Histories Opportunistic Infections

Physical Examination Investigations Health Maintenance

History General Health Past Histories Opportunistic Infections

Physical Examination Investigations Health Maintenance

#1: How did theycome to see you?#1: How did theycome to see you?

Referred by MD? Self-obtained test? Referred by gov’t or insurance? Contact tracing? Transfer of care? (not discussed this time)

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#2: Confirm HIV Diagnosis

HIV Ab ELISA

Confirmatory Western blot

Viral load

p24 antigen - not recommended

HIV Ab ELISA

Confirmatory Western blot

Viral load

p24 antigen - not recommended

Remember to discuss: 4 pointsRemember 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

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 pointsRemember to discuss: 4 points 2. treatability but incurability

try to normalise it a bit: “like diabetes…”

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 pointsRemember 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%

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 HealthGeneral 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

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 HistoryPast 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

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 InfectionsRisk for Opportunistic Infections

Occupational history

Travel history southwest US states, SE Asia, …

Pets

Occupational history

Travel history southwest US states, SE Asia, …

Pets

Physical ExaminationPhysical Examination Usual

Height & Weight

Dermatologic

Rectogenital, including swabs for SILs

Assessment of cognitive status (MMSE/MoCA)

Usual

Height & Weight

Dermatologic

Rectogenital, including swabs for SILs

Assessment of cognitive status (MMSE/MoCA)

InvestigationsInvestigations 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

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 MaintenanceHealth Maintenance

partner notification safe(r) sex practices drug rehabilitation/safe(r) use vaccinations (HAV, HBV, influenza,

pneumococcal, general) age-appropriate screening/prevention

partner notification safe(r) sex practices drug rehabilitation/safe(r) use vaccinations (HAV, HBV, influenza,

pneumococcal, general) age-appropriate screening/prevention

Decision to start HAARTDecision 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…

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…

SummarySummary

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!

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?

Questions?

Comments?

Concerns?