1. Initial Evaluation of the HIV+ Patient Mitchell D. Feldman, MD Professor UCSF

2. Case Dr W is seeing Ms T, a 35 year old woman, for a routine examination and for renewal of her medications. She reports being well but did have an episode of HSV that was treated last month. She is now better. She is currently married and monogamous. On further questioning, she reports a history of 5 sexual partners including a short-term relationship with a man who had used intravenous drugs. She has never been HIV tested. Dr W notes that the patients history of HSV prior to age 50 may be an early manifestation of immunosuppression. He decides to offer her HIV screening.

3. Who should be screened for HIV? Everyone? Many patients remain undiagnosed for years. These undiagnosed patients may infect others and may develop illnesses that could have been prevented. Many patients are unaware that they are at risk. Patients who ask for test should be screened.

4. HIV Risk Factors High-Risk Behaviors or exposures MSM sexual partner of IDU Multiple partners Sex workers History of STI, IDU Hep B or C Incarceration History of transfusion

5. Clues to HIV+ Clinical Signs/Clues Active TB HZV in healthy person < 50 History of: Hep B or C, thrush, diffuse LAN, weight loss, cervical cancer, unexplained anemia, leukopenia or thrombocytopenia

6. What is this? Primary HIV Infection

7. Occurs in 80%-90% of infected patients. Exposure to onset usually 2-4 weeks. Typical symptoms: fever, LAN, pharyngitis, rash, myalgias. Some have headache, aseptic meningitis, peripheral neuropathy, facial palsy. Lymphopenia followed by lymphocytosis, transient decrease in CD4.

8. Discussing a positive HIV result with the patient Be prepared! Be sensitive to stigma--this may be more difficult for patients than other bad news. Assess patients knowledge--and educate the patient about HIV transmission and prevention. “Prevention for Positives”

9. Initial History Common HIV related symptoms: Fevers, sweats, weight loss, diarrhea, rash HIV risk behaviors Inform current sexual partners of diagnosis Risk reduction Travel history, immunizations, pets, health- related behaviors Depression Assess adherence

10. Physical Examination Complete baseline physical examination Skin Seb. Derm, KS, folliculitis, fungal, warts, xerosis, molloscum Oropharynx Candidiasis, Oral hairy leukoplakia,periodontal disease

13. Hairy Leukoplakia

14. Candida Glossitis

15. Kaposis Sarcoma Maxillary Palate

16. Physical Examination Persistent generalized lymphadenopathy Rubbery, 1cm or less, not tender, nonspecific hyperplasia on biopsy Gynecologic exam/PAP q 6 months Consider anal PAP Neurologic exam Cognitive function

17. Laboratory Studies CBC and differential Mild normocytic anemia, leukopenia Platelets Common manifestation of HIV; often improves spontaneously as the disease progresses; bleeding rare unless plats below 25,000 Creatinine, LFT’s, lipids, glucose Viral Hepatitis Resistance Testing

18. Laboratory Studies CMV serologies Very high sero-prevalence among HIV+ Routine prophylaxis not recommended Toxoplasma IgG 20%-50% of HIV/toxo + will develop encephalitis Prophylaxis with TMP-SMX recommended when CD4 below 100/mm CD4, Viral load, HIV resistance resting

19. Laboratory Studies Syphilis Repeat syphilis serology yearly LP for pts with latent syphilis or with neurological signs PPD yearly TB prophylaxis recommended for all HIV-infected patients with: Positive PPD (5mm of induration) History of PPD+ Close contact of patient with active TB

20. Laboratory Studies Other tests to consider include: CXR Testosterone Anti-varicella IgG Anti-HAV

21. For asymptomatic persons

22. Prophylaxis of OI’s PCP CD4 < 200 (or <14%) History of PCP,thrush, or constitutional symptoms suggestive of advanced immunodeficiency TMP-SMX, dapsone, aero-pentamadine, atovaquone

23. Prophylaxis of OI’s MAC CD4 < 50 Clarithromycin 500mg bid Azithromycin 1200mg weekly Alternative is Rifabutin 300mg qd Fungal-- prophylaxis not recommended

24. Vaccines Give vaccines as early as possible For more advanced patients, defer vaccination until after HAART is initiated Live virus or bacteria vaccines should not be given (BCG, oral polio, oral typhoid, varicella-zoster, yellow fever)

25. Vaccines Influenza Transient rise in VL Defer in patients with advanced disease Hepatitis Hep B--first screen for past infection Hep A--especially for travel Tetanus-Diphtheria Same recs as for non HIV

26. Special Issues Proxy for healthcare decisions Wishes regarding terminal care Living will, DPA for health care Reporting requirements Community support Social isolation Build the doctor-patient relationship