- Section 2: Testing and Assessment
- Initial History
- Initial Physical Examination
- Initial and Interim Laboratory and Other Tests
- Interim History and Physical Examination
- HIV Classification: CDC and WHO Staging Systems
- CD4 and Viral Load Monitoring
- Risk of HIV Progression/Indications for ART
- Early HIV Infection
- Expedited HIV Testing
- Resistance Testing
- Karnofsky Performance Scale
- Occupational Postexposure Prophylaxis
- Nonoccupational Postexposure Prophylaxis
- Preventing HIV Transmission/Prevention with Positives
- Immunizations for HIV-Infected Adults and Adolescents
- Preventing Exposure to Opportunistic and Other Infections
- Opportunistic Infection Prophylaxis
- Latent Tuberculosis Infection
- Smoking Cessation
- Abnormalities of Body-Fat Distribution
- Insulin Resistance, Hyperglycemia, and Diabetes on Antiretroviral Therapy
- Coronary Heart Disease Risk
- Renal Disease
- Immune Reconstitution Inflammatory Syndrome
- Anal Dysplasia
- Candidiasis, Oral and Esophageal
- Candidiasis, Vulvovaginal
- Cervical Dysplasia
- Cryptococcal Disease
- Cytomegalovirus Disease
- Gonorrhea and Chlamydia
- Hepatitis B Infection
- Hepatitis C Infection
- Herpes Simplex, Mucocutaneous
- Herpes Zoster/Shingles
- Kaposi Sarcoma
- Molluscum Contagiosum
- Mycobacterium avium Complex Disease
- Mycobacterium tuberculosis
- Pelvic Inflammatory Disease
- Pneumocystis Pneumonia
- Progressive Multifocal Leukoencephalopathy
- Seborrheic Dermatitis
Publish date: April 2014
Conducting a thorough initial history and physical examination is important even if previous medical records are available. This is the best opportunity to get a complete picture of the patient's HIV disease status, comorbid conditions, and his or her physical and emotional condition, as well as to establish the basis for an ongoing relationship with the patient. Many of the conditions that put immunocompromised patients at risk of disease can be detected early, by means of a thorough assessment.
The information gathered through the initial history and physical examination will provide a comprehensive standardized database for the assessment and treatment of HIV-related problems, including acute intervention and ongoing prevention services and supportive care.
This chapter includes essential topics to cover during the clinic intake and examples of questions that can be used to elicit important information (the questions should be tailored to the individual patient). This can be completed during the initial visit or divided over the course of two or three early visits. For essential aspects of the physical examination to cover in an initial clinic intake visit, see chapter Initial Physical Examination.
|Category / Topics to Cover||Sample Questions|
|History of Present Illness|
|Active TB and TB Testing History|
|Antiretroviral Therapy (ART) History|
|Past Medical and Surgical History|
Do you have any chronic conditions, such as the following?
If so, do you receive medical care for these conditions?
|Gynecologic and Women's Health|
Have you ever had:
|Sexually Transmitted Diseases|
Have you ever had any of the following infections? If yes, when was last episode?
|Allergies; Medication Intolerance|
When was your last vaccination for the following:
Did you have chickenpox as a child, or were you vaccinated against chickenpox?
What about measles, mumps, and rubella?
|Sensitive Sexual and Gender History Questions|
Do you have a family history of:
Which family member(s), and what is their health status currently?
- Conduct a physical examination, focusing on subjective findings elicited in the history. (See chapter Initial Physical Examination.) Note: If significant time has elapsed between the review of symptoms (ROS) and the physical examination, perform another ROS.
A/P: Assessment and Plan
- Arrange for baseline/intake laboratory work. (See chapter Initial and Interim Laboratory and Other Tests.)
- Compose a problem list. Initiate a medication list (if appropriate).
- Refer the patient to social services, mental health care, local health department partner services, community and other resources, or other clinic services as needed.
During the current visit or a future visit:
- Perform immunizations for pneumonia (Pneumovax), influenza (as appropriate), and other immunizations as indicated. (See chapter Immunizations for HIV-Infected Adults and Adolescents.)
- Provide counseling on prevention of HIV transmission (e.g., safer sex and injection practices), as appropriate. See chapter Preventing HIV Transmission/Prevention with Positives.
A very important aspect of caring for HIV-infected individuals is educating patients about HIV infection, including goals of care and ways of achieving those goals.
Review the following with each patient:
- Disease course
- Significance of CD4 cell count and HIV viral load
- Possible treatment approaches, including initial discussion about the importance of ART for the patient's own health and for reducing risk of HIV transmission
- Disclosure (e.g., whom the patient may need to tell about HIV status, relevant legal requirements, approaches to disclosure)
HIV transmission prevention and risk reduction for HIV-infected individuals
(see chapter Preventing HIV Transmission/Prevention with Positives)
- Strategies to prevent transmission of HIV to uninfected partners and to prevent acquisition of sexually transmitted diseases, hepatitis, and other infections
- Safer-sex approaches, including the use of condoms or other latex barriers during sexual contacts
- Safer use of recreational drugs
- Maintaining a healthy weight
- Nutritional support resources, if appropriate
- Importance of including a nutritionist in medical care
- Stress reduction
- Rest and exercise to enhance a healthy mental state
- Importance of keeping medical appointments
- Need for adhering to any medication regimen and the consequences of missed HIV medication doses
- Aberg JA, Gallant JE, Ghanem KG et al.; HIV Medicine Association of the Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jan;58(1):e1-e34.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Accessed December 1, 2013.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed December 1, 2013.
- U.S. Department of Health and Human Services. Guide to Clinical Preventive Services, 2012: Recommendations of the U.S. Preventive Services Task Force. Accessed December 1, 2013.
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HRSA HAB Performance Measures
- HIV Medical Visit Frequency
Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. Learn More
- HIV Risk Counseling
Percentage of patients with a diagnosis of HIV who received HIV risk counseling in the measurement year. Learn More
- Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age-appropriate standardized depression screening tool AND, if positive, a follow-up plan is documented on the date of the positive screen. Learn More
- Substance Abuse Screening
Percentage of new patients with a diagnosis of HIV who have been screened for substance use (alcohol and drugs) in the measurement year. Learn More
Abbreviations for Dosing Terminology
- twice daily
- twice weekly
- intramuscular (injection), intramuscularly
- intravenous (injection), intravenously
- oral, orally
- Q2H, Q4H, etc.
- every 2 hours, every 4 hours, etc.
- every morning
- once daily
- every hour
- every night at bedtime
- four times daily
- every other day
- every evening
- three times daily
- three times weekly