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

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

#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)

#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 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 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): AIDS 1999 Oct 1; 13 (14):

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%

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

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

Risk for Opportunistic Infections  Occupational history  Travel history  southwest US states, SE Asia, …  Pets  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)  Usual  Height & Weight  Dermatologic  Rectogenital, including swabs for SILs  Assessment of cognitive status (MMSE/MoCA)

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

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

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…

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!

 Questions?  Comments?  Concerns?  Questions?  Comments?  Concerns?