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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 Patrick Willemot 2010 September 23
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Overview History General Health Past Histories Opportunistic Infections Physical Examination Investigations Health Maintenance History General Health Past Histories Opportunistic Infections Physical Examination Investigations Health Maintenance
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#1: How did they come 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)
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#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
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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 1. HIV biology *transmission (must get into the nitty-gritty) re-infection risk among seroconcordant partners mechanism of ARVs and resistance
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Remember 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.
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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% 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%
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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 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
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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 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
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Risk for Opportunistic Infections Occupational history Travel history southwest US states, SE Asia, … Pets Occupational history Travel history southwest US states, SE Asia, … Pets
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Physical 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)
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Investigations 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
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Health 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
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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… 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…
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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! 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!
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Questions? Comments? Concerns? Questions? Comments? Concerns?
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