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Initial Evaluation of the HIV+ Patient

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

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Initial Evaluation of the HIV+ Patient

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  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. Primary HIV Infection • 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

  11. Hairy Leukoplakia

  12. Candida Glossitis

  13. Kaposis Sarcoma Maxillary Palate

  14. 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

  15. 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

  16. 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

  17. 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

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

  19. For asymptomatic persons

  20. 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

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

  22. 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)

  23. 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

  24. 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

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