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UPDATE: Primary Care Approach to the HIV-Infected Patient

Updated November 2014

What’s New — November 2014 Update


I. INTRODUCTION

Updated April 2011

RECOMMENDATIONS:
Primary care clinicians should be capable of evaluating HIV-infected patients at all stages of HIV infection and should consult with a clinician who has experience with management of antiretroviral therapy (ART) according to current guidelines (see Antiretroviral Therapy). (III)

Clinicians should involve patients in decisions regarding HIV treatment. (III)

As the treatment of HIV has continued to reduce mortality and increase the number of clinically stable patients, the primary care approach to HIV-infected patients has evolved. In addition to the management of HIV infection, a renewed emphasis on general preventive medicine has emerged. The following aspects of care are discussed:

  • Medical history and physical examination
  • Laboratory assessments and diagnostic testing
  • Health maintenance and preventive care
  • Coordination of care
  • Use of chronic care services

For treatment considerations, see Antiretroviral Therapy, which includes recommendations regarding initiation of ART, selection of an ART regimen, monitoring for ART-specific side effects, optimizing treatment adherence, and changing regimens.

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II. COMPREHENSIVE HIV-RELATED HISTORY AND ONGOING ASSESSMENTS

Updated November 2014

RECOMMENDATIONS:
Clinicians should obtain a baseline and an ongoing HIV-related history according to Table 1. (AI)

When obtaining an HIV-related history, clinicians should:

  • Use vocabulary that patients can understand, regardless of educational level (AIII)
  • Assess patients’ health literacy* (AIII)
  • Determine the language in which the patient wishes to communicate and use a professional interpreter or sign language services when language or hearing barriers exist (AIII)

Clinicians should stress the confidential nature of discussions regarding sexual history, mental health, and substance use. (AIII)

Clinicians should address the importance of partner notification with HIV-infected patients. HIV and STI testing for partners, including testing for viral hepatitis, should be available onsite (for more information about partner notification, see www.health.ny.gov/diseases/aids/regulations/partner_services/index.htm).

Clinicians must report confirmed new cases of HIV according to New York State Law and should educate patients with reportable illnesses about the potential for confidential follow-up from the New York State Department of Health or the patient’s local health department (for more information about required reporting, see www.health.ny.gov/diseases/aids/regulations/partner_services/index.htm).


Detailed information regarding patients’ health, ongoing health risks, and previous HIV treatment should be obtained during the baseline history (see Table 1). This information establishes the framework for ongoing HIV care. Effective communication between the patient and provider is essential for including patients in the decision-making process regarding their medical care.† All members of the healthcare team should provide information that is well organized and easy to understand. When language or hearing barriers exist, clinicians should use a professional interpreter or language services.

* As defined by the National Network of Libraries of Medicine,1 health literacy includes the ability to understand prescribing instructions, appointment slips, medical education brochures, doctor’s directions and consent forms and the ability to negotiate complex healthcare systems. Health literacy requires reading, listening, analytical, and decision-making skills, as well as the ability to apply these skills to health situations. More information about health literacy, including a list of resources, is available at: http://nnlm.gov/outreach/consumer/hlthlit.html. Professional development and training for adult education is available through the Literacy Assistance Center.
† For more information, see the Salzburg Statement on Shared Decision Making.2

For patients who have received HIV care from previous providers, past medical records should be obtained whenever possible. The New York State standard consent form is available at: www.health.ny.gov/forms/doh-5032.pdf. Medical records may be available electronically for patients who receive care from providers participating in regional health information organizations (RHIOs). With standardized consent forms signed by patients, providers enrolled in RHIOs are able to share medical information electronically.

Key Point:
Clinical data exchanges, often known as RHIOs (regional health information organizations), continue to expand in New York State. Clinicians should be familiar with RHIOs in their areas and understand the consent procedures used for them. For additional information, refer to the New York eHealth Collaborative (NYeC).


When medical records are not available directly from previous providers, patients may be encouraged to bring their past medical records or any medical information they may have in their possession. However, clinicians should be aware that patients may not wish to disclose to their previous providers that they are changing providers, and fees may be associated with requests for medical records.

Although clinicians may obtain all elements of a comprehensive history during the first few visits to the clinic, it is important to address sexual behavior, mental health, and alcohol and substance use, including illicit use of prescription drugs, during the initial and subsequent clinical encounters. The confidential nature of these discussions should be stressed. Clinicians should note that although the patient may choose not to disclose all pertinent personal information during the first visit, a sympathetic and nonjudgmental attitude can help establish trust and facilitate discussion of these issues during subsequent visits.

Clinicians who are uncomfortable asking questions about substance and alcohol use or sexual risk behaviors should seek training to enhance their comfort level.‡

‡ The NYSDOH Clinical Education Initiative and the NY/NJ AIDS Education Training and Center provide HIV-related educational resources and training for providers. Training in methods of motivational counseling and in prevention interventions, such as Diffusion of Effective Behavioral Interventions (DEBIs), is also available.

Table 1 lists the elements of a comprehensive history and ongoing assessments that are particularly important for HIV-infected patients.

Table 1: Comprehensive History and Ongoing Assessments for HIV-Infected Patients
Assessment Frequency
Contact Information and Past Medical Care
  • Contact information—patient contact information, as well as contact person for emergencies or if unable to reach patient
    At each visit
    (Note: Discuss disclosure of medical information with the patient and document whether the patient consents to sharing information with contacts)
    • Review sources of past medical care; obtain medical records whenever possible
    Baseline
    Current Medical Status
    • Recent and current symptoms and illnesses, recent hospitalizations
    At each visit
    HIV History
    • HIV exposure history
      • Date and place of the diagnosis
      • Route of exposure, if known
    Baseline
    See Table 3
    • Nadir CD4 and peak viral load
    Baseline
    • ART-related history
      • Current and previous ART regimens
      • Date of initiation of ART
      • Reasons for changes in ART
      • Previous adverse drug reactions, including hypersensitivity reactions to prior therapies such as NNRTIs, ABC, and sulfonamides
      • Challenges with adherence to therapy
      • History of drug resistance if known
    Baseline
    Baseline
    • Patient’s understanding of HIV disease and treatment (health literacy assessment)
    Baseline and at least annually
    At baseline and whenever a new partner is reported
    (Note: Inquire about new partners at each visit)
    General History
    • Past hospitalizations and surgeries
    Baseline
    • Tuberculosis history
      • Possible recent exposure to tuberculosis
      • History of positive TB skin test, commonly known as PPD
      • History of TB disease or treatment of tuberculosis or LTBI
    Baseline and at least annually
    • History of viral hepatitis infection (HAV, HBV, HCV)
    Baseline
    (Note: Also, inquire about past treatment for HCV)
    • History of varicella zoster virus infections: chickenpox and herpes zoster
    Baseline
    • Current prescription and nonprescription medications, including treatment for opioid dependence (methadone and buprenorphine); hormones; OTC agents (NSAIDs, antihistamines, dietary supplements, vitamins); and other nonprescription medicines, including complementary and alternative medicines
    Conduct thorough medication history at each visit (see Appendix A. Medication Evaluation Form)
    Baseline and at least annually
    Baseline and at least annually
    • Transfusion or blood product history, especially before 1985
    Baseline
    Baseline
    Baseline
    • History and results of cancer screening
    See Table 5
    • Allergies
    Baseline and at least annually
    • Place of birth
    Baseline
    • Complete family medical history, including chronic medical conditions and cancer history
    Baseline
    • Travel history
    Baseline and at least annually
    Baseline
    • Occupational history
    Baseline
    • Pets/animal exposures
    Baseline and at least annually
    Psychosocial
    • Housing status and names and contact information for housing and case management providers, educational level
    Baseline and at least annually
    (Note: Housing status and contact information should be closely monitored for patients with unstable living situations)
    • Social support and stability of personal relationships
      • Family and partner contacts
      • People whom patients have informed of their HIV status
    Baseline and at least annually
    (Note: Social support should be closely monitored for patients with unstable living situations)
    • Home healthcare
    Baseline and at least annually
    • Employment and insurance status
    Baseline and at least annually
    Baseline
    • Legal
      • Living will and healthcare proxy
      • Permanency planning for dependent children
      • Court-related issues (divorce, child custody, immigration status, probation status)
    Baseline and at least annually
    • How the patient is coping with his/her HIV status
    Baseline and at least annually
    Mental Health
    Routine mental health screening at baseline and at least annually (see the Mental Health Screening Reference Guide)
    Baseline and at least annually (see the Mental Health Screening Reference Guide)
    • Past or present experience of violence and trauma (including physical and mental abuse or exposure to violence)
      • Intimate partner violence
    Baseline and at least annually
      • Elder abuse
    Baseline and at least annually for patients >65 years of age
      • Abuse during childhood
    Baseline
    • Psychopharmacologic treatment
    At each visit
    (Note: Assess medication adherence, if applicable)
    • Past psychiatric hospitalizations
    Baseline
    • Names and contact information for mental health providers
    Baseline and at least annually
    Substance Use
    • Types of drugs; past and current use
      • Tobacco
      • Alcohol
      • Street drugs—marijuana, cocaine or crack, heroin, crystal methamphetamine, MDMA/ecstasy, hallucinogens (e.g., LSD, PCP), ketamine
      • Illicit use of inhalants—glue, nitrous oxide
      • Illicit use of prescription drugs—prescription opioids (e.g., Vicodin, codeine), benzodiazepines, amphetamines
    Routine substance use screening at baseline and at least annually (see Smoking Cessation in HIV-Infected Patients, Screening and Ongoing Assessment for Substance Use, and the Substance Use Screening Reference Guide)
    • Frequency of use and usual route of administration
    Baseline and at least annually
    • Risk behaviors—drug/needle-sharing, exchanging sex for drugs, sexual risk-taking while under the influence of drugs or alcohol
    Baseline and at least annually
    • Names and contact information for substance use providers
    Baseline and at least annually
    Sexual
    • Sexual activity and past and current partners
    Baseline and at each visit
    • Sexual risk behavior assessment:
      • Sexual practices—vaginal, anal, oral
      • Knowledge about and use of latex or polyurethane barriers
    Baseline and at least every 4 months (for additional information about sexual risk behavior screening, see Prevention With Positives: Integrating HIV Prevention Into HIV Primary Care)
    See Table 3 for ongoing STI assessment
    • Sexual function (libido, erectile dysfunction, etc.) and use of sex-enhancing agents or testosterone replacement
    Baseline and at least annually
    Review of Systems
    • Constitutional
      • Malaise or fatigue, weakness, fevers, night sweats, changes in appetite, changes in sleep, emotional well-being
    At each visit
    At each visit
    (Note: Direct questioning about pain is important because patients may not otherwise report symptoms until after they have already caused significant morbidity)
    • Eyes—change in vision, including blurry vision, double vision, flashes of light, loss of vision, use of glasses, legally blind or blind
    Baseline and at least annually
    • Head, ears, nose—headache, dysphagia, odynophagia, discharge
    Baseline and at least annually
    • Oral
      • Name and contact information for dental provider and date of last visit
      • Dental pain, denture fit, mastication
    Baseline and at least annually
    • Pulmonary—cough, dyspnea at rest or on exertion, hemoptysis
    Baseline and at least annually
    • Cardiac—chest pain, palpitations, heart murmur
    Baseline and at least annually
    Baseline and at least annually
    • Genitourinary:
      • Urinary symptoms (dysuria, incontinence, frequency)
      • Vaginal pain
      • OB/GYNmenstrual status, bleeding, infections, last Pap test and result
      • Perimenopausal or menopausal symptoms
      • History of prostate disorders
    Baseline and at least annually
    • Extremities—muscle tenderness
    Baseline and at least annually
    • Neurologic—tingling, burning, pain, or numbness in the extremities
    Baseline and at least annually

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    A. Psychosocial

    A psychosocial assessment is used to identify not only the patient’s basic psychosocial information but also circumstances that may require additional services. Important elements of a psychosocial assessment include the following:

    • Stability of housing,* employment, government assistance, and level of education
    • Support network and safety:
      • Does the patient have contact with family and friends?…Are they aware of the patient’s HIV status?
      • Does the patient have a partner?…Is the patient afraid of his/her partner or someone else close?
    • Whether the patient requires home healthcare
    • Gender identity†:
      • With which gender does the patient identify?
      • Does the patient prefer to be referred to as ‘Ms.’ or ‘Mr.’?…What is the patient’s preferred name?
    • Legal issues, including end-of-life arrangements, permanency planning for dependent children, immigration status, probation status
    • How the patient is coping with his/her HIV status

    * Housing status and contact information should be closely monitored for patients with unstable living situations.
    See Care of the HIV-Infected Transgender Patient.

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    B. Mental Health and Substance Use

    RECOMMENDATIONS:
    All HIV-infected patients should receive baseline and ongoing assessment for the following (AI):

    • Mental health disorders
      • Depression (every visit)
      • Anxiety (at least annually)
      • Post-traumatic stress disorder (at least annually)
    • Cognitive function (at least annually)
    • Sleep habits and appetite assessment (every visit)
    • Alcohol and substance use (at least annually*)
    • Suicidal/violent ideation (every visit)
    • Psychosocial status, including domestic violence, family and social support, and housing status (at least annually)

    * At-risk drug and alcohol users should be screened more frequently to identify escalation of present levels of use or harmful consequences from use.

    Clinicians should use selected brief screening instruments when performing the mental health and substance use assessment. The chosen screening instruments should be tailored for optimal use at initial, annual, and interim visits and adjusted for the patient’s mental health or substance use history (see Mental Health Screening Tools and the Substance Use Screening Reference Guide). (AIII)

    Clinicians should refer patients to appropriate mental health and substance use treatment providers when indicated. (AII)

    A number of brief screening tools for mental health and substance use assessment are available for use by primary care providers during the history-taking process. For most patients, baseline mental health and substance use screening requires approximately 10-20 minutes. The chosen screening tools should be tailored for optimal use at initial, annual, and interim visits.

    When performing substance use screening, clinicians should discuss how alcohol and substance use affect the patient’s health. Judgmental language that can exacerbate stigma, such as “substance abuse” or “alcohol abuse,” should be avoided and screening should be adjusted for the patient’s substance use history.

    For additional information regarding mental health and substance use screening and treatment, including mental health and substance use screening questions and instruments, refer to:

    For more information regarding neuropsychological assessment, see Section III. K. Neuropsychological Examination. For scripted dialogue for assessing substance use, refer to Screening and Ongoing Assessment for Substance Use.

    Key Point:
    For mental health, substance use, or psychosocial issues that are potential barriers to treatment adherence, clinicians should work with the patient’s case manager to provide necessary medical guidance. When case managers are unavailable, clinicians should refer their patients to social workers who can provide psychosocial services and facilitate referrals to supportive services.

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    C. Sexual History

    When obtaining a sexual history, terms such as lesbian, homosexual, or gay should be avoided. Questions should relate to the patient’s behavior and not to “sexual identity.” The information derived will be more useful to the clinician and the questions less threatening to many patients. For example, when talking to a male patient, the clinician should ask, Are your sexual partners men, women, or sometimes both? because the patient may not identify with the words “homosexual” or “gay.”

    For information regarding risk-reduction counseling related to sexual transmission, refer to Prevention With Positives: Integrating HIV Prevention Into HIV Primary Care.

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    III. COMPREHENSIVE PHYSICAL EXAMINATION

    Updated November 2014

    RECOMMENDATION:
    Clinicians should perform a baseline and annual comprehensive physical examination for all HIV-infected patients. All standard elements of a comprehensive physical examination should be performed, with particular attention to areas potentially affected by HIV (see Table 2).

    Table 2 lists elements that warrant particular attention in HIV-infected patients.

    Table 2: HIV-Related Physical Findings
    (Note: Except where indicated, each element should be performed at baseline and at least annually)
    Examination Assessment
    Vital signs (blood pressure, pulse, temperature), general appearance, weight, and body mass index
    • Assess at each visit
      Note: General appearance such as body habitus, lipoatrophy (wasting and facial wasting), frailty, weakness, difficulty ambulating, use of ambulatory aides or wheelchair
    Skin

    Related Guidelines: Management of STIs

    Lymphatic
    • Note: Significant abnormalities may present as clusters of large nodes, asymmetry, tenderness, or sudden increases in size or firmness of nodes
    • Pay particular attention to posterior cervical, cervical, supraclavicular, submental, axillary, epitrochlear, and inguinal node enlargement, tenderness, firmness, drainage, asymmetry
    Eyes
    • Note: Icterus, dryness, redness, CMV retinitis, HIV-related retinopathy
    • For asymptomatic patients without significant history and with CD4 counts ≥50 cells/mm3: Follow standard schedule for complete ophthalmic examination for all adults (see Standard Ophthalmic Examination)
    • For patients with CD4 counts <50 cells/mm3: Complete ophthalmic examination by an ophthalmologist at baseline and every 6 months

    Related Guidelines: Ophthalmologic Complications

    Head, ears, nose, throat
    • Evidence of sinusitis, hearing loss, or deafness
    Oral

    Related Guidelines: HIV and Oral Health

    Neck
    Chest and breast
    • Masses, nipple discharge
    Musculoskeletal
    • Muscle wasting, joint swelling
    Genitourinary
    • Perform complete female pelvic examination and female and male genital examination
    • Note: Vaginal or penile discharge, ulcers, blisters, warts, tenderness, masses, vaginal dryness, cervical abnormalities

    Related Guidelines: Management of STIs, Gynecological Care

    Rectal
    • Perform rectal examination, including visual inspection and digital rectal examination
      Note: Lesions, hemorrhoids

    Related Guidelines: Anal Dysplasia and Cancer

    Neurologic

    Related Guidelines: Neurologic Complications of HIV Infection

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    A. General Appearance, Vital Signs, and Weight

    RECOMMENDATIONS:
    Clinicians should note abnormalities and changes in general appearance, body habitus, physical well-being, frailty, and mobility.

    Clinicians should assess vital signs, weight, and body mass index (BMI) at each visit.

    General appearance and vital signs should be assessed at each visit. Body mass index may be used to tailor patient education and recommendations for weight loss/gain and exercise (refer to Section V. Health Promotion and Behavioral Health Counseling).

    Key Point:
    Observation of patient’s body habitus and ambulation may detect frailty and decreased mobility, which are increasing as people with HIV age and as more people are diagnosed with HIV at older ages. Weight gain or loss can be the first sign of therapy success or failure, even before laboratory test results are available.

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    B. Pain

    RECOMMENDATIONS:
    Clinicians should:

    • Ask HIV-infected patients about pain at each visit
    • Use a validated pain scale to track pain over time
    • Document the severity and location of pain and precipitating factors
    • Attempt to identify underlying causes of pain and respond with efforts to alleviate it
    • Provide referral to a pain-management specialist when the patient’s symptoms do not respond to treatment in the primary care setting

    Clinicians should not deny treatment of pain because of a patient’s past or current history of addiction; clinically appropriate pain management in substance users requires careful individualized judgment (see Pain in the HIV-Infected Substance User).

    Clinicians should assess patients with chronic pain for fatigue and mental health disorders (see the Mental Health Screening Reference Guide and Somatic Symptoms).

    HIV-infected patients are at increased risk for development of certain painful conditions, particularly neuropathy, which can be due to medications, diabetes, or the underlying HIV infection. Some opportunistic infections are painful, such as chronic herpes simplex virus or varicella zoster virus. Many experts encourage the routine use of pain scales, such as the Wong-Baker Faces Pain Rating Scale or the Numeric Rating Scale, to standardize pain assessments and determine how pain may affect activity and other aspects of function.

    Treatment of pain can be complicated if the patient has a history of substance use, and the extended use of opioid analgesics and benzodiazepines may require consultation with substance use treatment professionals. However, no patient should be denied treatment for pain because of a history of substance use. In some cases, it may be useful for the clinician and patient to work together to establish a clear oral or written treatment agreement. For further guidance on treatment agreements and pain management in HIV-infected substance users, refer to Pain in the HIV-Infected Substance User.

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    C. Skin

    Dermatologic findings, such as rash, lesions of Kaposi’s sarcoma, and vasculitis, may all be the first signs of progression of HIV, comorbid diseases, or toxicities of treatment. Seborrheic dermatitis can be an indicator of immune deficiency. Maceration of the gluteal cleft may not be noticed by the patient but could be a result of Candida infection or herpes simplex virus. Molluscum contagiosum may appear slightly larger and in more clusters in HIV-infected patients and be more widespread. Onychomycosis may involve all fingernails and toenails. Diffuse folliculitis with associated pruritus may occur with immunodeficiency. Spider angiomata or palmar erythema may be signs of cirrhosis.

    Examples of dermatologic manifestations of HIV are provided in Appendix B.

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    D. Lymphatic Examination

    Generalized lymphadenopathy is a common finding during all stages of HIV disease but does not correlate with prognosis or disease progression. Lymphadenopathy may not be as prominent in older patients.

    Reactive lymph nodes may be prominent in early stages of HIV, diminish as disease progresses, and return with immune reconstitution after effective ART has been established. Presentation of asymmetry, clusters of large nodes, or sudden increase in size, firmness, or tenderness of nodes may signal infection, malignancy, or opportunistic infections. Lymph node clusters that are normally quiescent, including posterior cervical chain, submental, supraclavicular, epitrochlear, axillary, and femoral nodes, should not be overlooked.

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    E. Eyes: Ophthalmologic Assessment and Referral

    RECOMMENDATIONS:
    Patients with CD4 counts <50 cells/mm3 should be examined by an ophthalmologist at baseline and every 6 months. (AIII)

    Patients with visual disturbances or unremitting ocular symptoms, regardless of CD4 cell count, should be evaluated by an ophthalmologist. (AIII)

    Asymptomatic patients without a significant history of eye conditions who have CD4 cell counts ≥50 cells/mm3 should receive retinal examinations according to the standard schedule for all adults (see Standard Ophthalmic Examination).

    Eye examinations by an ophthalmologist, ideally one experienced with the ocular complications of HIV infection, are important, especially for patients with low CD4 counts who are at higher risk for CMV retinitis resulting from declining immune function. A baseline examination may be indicated for patients with low CD4 counts (<200 cells/mm3) who are initiating ART. This examination should include a dilated funduscopic assessment with indirect ophthalmoscopy. See Ophthalmologic Complications of HIV Infection.

    HIV-infected persons may experience icterus due to atazanavir-containing regimens,3 acute hepatitis due to viruses or medications, or cirrhosis due to chronic viral hepatitis or alcohol abuse.

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    F. Head, Ears, Nose, Mouth, Throat, and Neck

    RECOMMENDATIONS:
    Clinicians should ascertain whether HIV-infected patients have a regular oral health provider and should refer:

    • Dentulous patients for hygiene and intraoral examinations every 6 months, including screening for dental caries, gum disease, and oral cancer (AIII)
    • Edentulous patients for intraoral examinations annually, including assessment for denture fit and screening for mucosal lesions including oral cancer (AIII)

    All referrals should be documented in the patient’s medical record.

    As part of the annual physical examination, clinicians should inspect the patient’s oral cavity.

    Clinicians should make a dental referral for every HIV-infected patient under their care. The patient’s access to regular and urgent dental care should be identified. As part of the annual physical examination, the clinician should visually examine and palpate the patient’s lips, labial and buccal mucosa, all surfaces of the tongue and palate, and the floor of the mouth. The gingiva should be examined for signs of erythema, ulceration, or recession. Numerous HIV-related diseases may present with oral manifestations. Leukoplakias associated with tobacco use and HPV exposure are common; oral hairy leukoplakia, while uncommon, may also be present. Kaposi’s sarcoma and lymphoma may first occur in the face, mouth, throat, or neck. See Oral Health Complications in the HIV-Infected Patient.

    Although HIV infection itself does not increase the likelihood of upper respiratory infections, sinusitis and otitis occur more frequently in the HIV-infected population and can be severe and chronic.

    An increased dorsocervical fat pad is a common manifestation of lipodystrophy. Although primarily a cosmetic concern, prominent dorsocervical fat pads may cause significant distress and depression, increase stigma associated with HIV/AIDS, limit neck mobility, and be associated with back pain.

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    G. Respiratory/Chest

    The evaluation of respiratory symptoms in HIV-infected patients can be challenging because those symptoms may be due to a broad spectrum of illnesses that may or may not be related to HIV. HIV-related conditions comprise a wide range of infections, including neoplasms and opportunistic infections such as pneumonia, pleural effusion, and empyema. Symptoms may include chest pain, dyspnea, cough, pleurisy, and hemoptysis. Chronic lung disease is increasingly common among people with HIV infection due to smoking, aging, and improved survival after Pneumocystis jirovecii pneumonia (PCP). The prevalence of smoking among HIV-infected patients is 2- to 3-fold higher than that of the general population.4

    Key Point:
    The risk of mortality associated with smoking has been found to be significantly increased among HIV-infected patients (61.5%) compared with those not infected with HIV (34.2%).5


    Evidence also suggests that lung cancer may be increased in HIV infection independent of smoking history.6-8 Pulmonary hypertension can cause respiratory symptoms and is increased in patients with HIV, especially those with untreated advanced HIV/AIDS.

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    H. Cardiovascular

    Untreated or inadequately suppressed HIV infection is associated with increased risk of myocardial infarction and stroke; this may be related to inflammatory responses due to an induced state of chronic immune activation,9-11 as well as lower CD4 counts12,13 and higher viral load levels.9 Although the risk of cardiovascular disease may be reduced with ART compared with untreated HIV, metabolic complications, including cardiovascular disease, have been associated with long-term HIV treatment.14-16 Older nucleoside reverse transcriptase inhibitors (e.g., zidovudine, didanosine) may cause cardiomyopathy17; however, this effect is rare.

    Injection drug users are at increased risk for endocarditis and mycotic pseudoaneurysms.18 A number of complications of advanced HIV disease or AIDS can involve the cardiovascular system. Tuberculosis, CMV, toxoplasmosis, lymphoma, and other opportunistic infections and cancers can involve the heart or blood vessels. Manifestations include myocarditis, pericardial effusion, chronic heart failure, cardiomyopathy, and vasculitis.

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    I. Gastrointestinal

    Hepatosplenomegaly may be caused by infection, medications, alcohol, or other infiltrative disease processes. Certain combinations of antiretroviral agents may increase the likelihood of finding multiple lipomata in the subcutaneous fat. Increased visceral fat associated with ART may cause abdominal distension, requiring radiologic imaging to evaluate for other processes such as ascites. Chronic hepatitis B and C infection increase the risk of hepatocellular cancer, cirrhosis, portal hypertension, encephalopathy, coagulopathy, and ascites. Tuberculosis, lymphoma, Kaposi’s sarcoma, CMV, and other conditions can involve abdominal structures. Increased rates of pancreatitis are found with excessive alcohol use.19

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    J. Genitourinary

    RECOMMENDATIONS:
    Clinicians should examine all HIV-infected patients for anogenital ulcerative lesions.

    Clinicians should perform a gynecologic examination in all HIV-infected women or refer them to a gynecologist at baseline and at least annually.

    At baseline and as part of the annual physical examination for all HIV-infected adults, regardless of age, clinicians should:

    • Inquire about rectal symptoms, such as itching, bleeding, discharge, diarrhea, or pain
    • Perform a visual inspection of the perianal region
    • Perform a digital rectal examination

    Clinicians should refer any patient with abnormal anal physical findings, such as warts, hypopigmented or hyperpigmented plaques/lesions, lesions that bleed, or any other lesions of uncertain etiology, for high-resolution anoscopy and/or examination with biopsy of abnormal tissue.

    Transgender patients should receive a genitourinary examination according to standards of care for their anatomy. Male-to-female transgender patients with a neo-vagina should receive pelvic examinations according to HIV care guidelines for natal females. Before performing a pelvic examination, the clinician should explain the medical reasons for the examination (see Care of the HIV-Infected Transgender Patient). (AIII)

    Because patients may be reluctant to report signs or symptoms of sexually transmitted infections (STIs) or other genital abnormalities, clinicians should carefully inspect the anogenital area for discharge and ulcerative lesions, including lesions associated with HPV, syphilis, and classic genital herpes simplex virus (HSV), as well as atypical HSV presentations, such as nonhealing gluteal cleft maceration.

    In addition to a genital examination, a careful pelvic examination is essential for natal women, as well as male-to-female women who have a neo-vagina.

    During the rectal examination, evidence of skin abnormality around the anus should be referred for high-resolution anoscopy (HRA) and/or examination with biopsy of abnormal tissue. For additional information, see Anal Dysplasia and Cancer.

    As people with HIV age, increasingly important issues include sexual dysfunction, prostate health, and peri- and postmenopausal illness (see Medical Care for Menopausal and Older Women With HIV Infection).

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    K. Neuropsychological Examination

    RECOMMENDATIONS:
    As part of the routine mental health assessment for HIV-infected patients, clinicians should assess cognitive function (see Section II. B. Mental Health and Substance Use).

    Clinicians should assess gait, cranial nerves, reflexes, and balance in HIV-infected patients, as well as examine for sensory, vibratory, motor, and cerebellar abnormalities.

    Clinicians should refer HIV-infected patients with more complex suspected or proven peripheral neuropathy syndromes to a neurologist to assist with the diagnosis and management.

    HIV-related neurologic changes can occur, even without the neurologic side effects of medications, especially as HIV disease progresses. For further information regarding neurologic complications, including screening tools for cognitive impairment, see Neurologic Complications of HIV Infection and Cognitive Disorders and HIV/AIDS.

    Physical and occupational therapists may provide assessment and collaborative management for patients with frailty, balance and sensory deficits, and pain.

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    IV. LABORATORY ASSESSMENT AND DIAGNOSTIC TESTING

    Updated March 2011, currently under revision

    RECOMMENDATION:
    Clinicians should order appropriate laboratory assessments and screening tests for management of HIV-infected patients (see Table 3). (III)

    Table 3: Routine Laboratory Assessment and Diagnostic Screening
    Assessment Diagnostic Screen Frequency
    Virologic assessment • Quantitative HIV RNA testing for viral load assessment; the same testing laboratory should be useda Recommended intervals differ based on length of suppression, CD4 count, and general adherence to medical care, including visit attendance, see Antiretroviral Therapy, Section VI.A: Virologic and Immunologic Monitoring
    • Resistance testing 1) Baseline, regardless of whether ART is being initiated (genotypic testing)
                and
    2) Prior to initiating treatment in ART-naïve patients (genotypic testing)
                and
    3) When patients experience virologic failure or incomplete viral suppression while receiving ART (genotypic and/or phenotypic testingb)
    Immunologic assessment • CD4 lymphocyte count and percentage; to produce reliable results, the same testing laboratory should be used Recommended intervals differ based on clinical stability and level of virologic suppression, see Antiretroviral Therapy, Section VI.A: Virologic and Immunologic Monitoring
    Tuberculosis evaluation • TSTc or other FDA-approved test for patients with no previous history of TB or no previous positive TST
    • Chest X-ray for patients known to have a history of TB or known to be TST positive
    Baseline and annually
    Screening for sexually transmitted infectionsd • RPR or VDRL for syphilis with verification of positive test by confirmatory FTA-Abs or TP-PA • Baseline and at least annually; every 3 months for patients with continued high-risk behavior
    • Gonorrhea and chlamydiae
        o Sexually active women <25 years of age
        o Women ≥25 years of age with risk factorsf
        o All HIV-infected men with ongoing high-risk behavior
    • Baseline and at least annually
    Cytologic screening • Cervical Pap tests • Baseline, 6 months after baseline, then annually as long as results are normalg
    • Anal Pap tests
        o For men who have sex with men
        o Any patient with a history of anogenital condylomas
        o Women with abnormal cervical/vulvar history
    • Baseline and annually
    Hematologic assessment • Complete blood count, including differential Baseline and at least every 4 months
    Renal assessment • Urinalysis, total protein, and albumin • Baseline and at least annually
    • Serum creatinine and calculated glomerular filtration rate (GFR) • Baseline and at least every 4 months
    • Blood urea nitrogen (BUN) • Baseline and at least every 6 months
    Metabolic assessment • Fasting blood glucose
    • Fasting lipid profile, including cholesterol
    • For patients receiving ART: before initiating ART, 3 to 6 months after initiating, and annually thereafter
    • For patients not receiving ART: at baseline and annually
    Hepatic assessment • Hepatitis A serology
    • Hepatitis B serology
    • Baseline
    • Hepatitis C serologyh • Baseline; baseline and annually for patients at riski
    • Serum liver enzymes • Baseline and at least every 4 months for patients receiving ART
    Additional testsj • Amylase and lipase testing
    Toxoplasma gondii antibody screening
    • Varicella antibody screening for adults without a history of chickenpox
    Baseline
    a The initial test performed in an ART-naïve individual should be an assay that can document a potentially high viral load level. All patients with a viral load <400 copies/mL should be retested with an assay that can detect <50 copies/mL; the same testing laboratory and the same assay should be used thereafter.
    b For additional information regarding genotypic and phenotypic testing, refer to Section VI. B. HIV Resistance Assays in Antiretroviral Therapy.
    c Tuberculin skin test, commonly known as PPD.
    d Patients who continue to engage in unsafe sexual practices are at increased risk for other STIs. Patients with any other STIs, whether ulcerative or not, are at higher risk for HIV transmission. Recent increases in STIs among men who have sex with men warrant screening of asymptomatic sexually active patients20 (see Management of STIs in HIV-Infected Patients).
    e All sites of possible exposure are screened. For specific recommendations regarding the types of assays used, refer to Gonococcal and Chlamydial Infections in Management of STIs in HIV-Infected Patients).
    f Risk factors for women ≥25 years of age include one of the following: recent STI, having multiple sexual partners, having had a new sexual partner, or having a sexual partner with symptoms of an STI.
    g Colposcopy should be performed for all HIV-infected women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis. Abnormal Pap tests should be repeated every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with cervical HSIL also should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue.
    h A qualitative HCV RNA PCR should be obtained when no hepatitis antibodies are detectable in a patient with elevated serum liver enzymes and risk factors for HCV.
    i HIV-infected patients who are seronegative for HCV but have continued high-risk behaviors should be screened at least annually for HCV. Individuals at high risk include injection drug users, men who have sex with men without barrier protection, or anyone with multiple sexual partners (see Hepatitis C Virus).
    j Depending on the patient’s history, these additional baseline tests may be needed.

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    A. Virologic Assessment

    RECOMMENDATIONS:
    Clinicians should use an assay with a high upper limit of detection (e.g., ≥750,000 copies/mL) for initial measurement of HIV viral load in ART-naïve patients. (III)

    Clinicians should obtain viral load before vaccinations and not during intercurrent illness because these situations may lead to a transient elevation in viral load. (III)

    Clinicians should perform resistance testing under the following circumstances:

    • At baseline, regardless of whether ART is being initiated (genotypic testing)
    • In ART-naïve patients before initiation of ART (genotypic testing)
    • In patients experiencing treatment failure or incomplete viral suppression while receiving ART (genotypic and/or phenotypic testing)

    Clinicians should seek expert consultation for interpretation of genotypes. (III)

    There are several methods of measuring HIV viral load levels (e.g., PCR, bDNA, NASBA), each with different ranges (e.g., standard, ultrasensitive). The same assay should be used consistently to avoid confusion.

    The initial test performed in an ART-naïve individual should be an assay that can document a potentially high viral load level. All patients with a viral load <400 copies/mL should be retested with an assay that can detect ≤50 copies/mL. Newer assays have a greater dynamic range than either the standard or ultrasensitive assay (e.g., 40 to 10,000,000 copies/mL). The range of detection for the standard PCR assay is 400 to 750,000 copies/mL, whereas the range for the ultrasensitive assay is 50 to 75,000 copies/mL (see Diagnostic, Monitoring, and Resistance Laboratory Tests for HIV).

    Key Point:
    Regular monitoring of HIV RNA levels remains the most meaningful measure of effective ART (for recommended intervals, see Antiretroviral Therapy, Section VI.A: Virologic and Immunologic Monitoring).


    Resistance testing should be performed 1) at baseline in the setting of acute infection, regardless of whether ART is being initiated (genotypic testing); 2) prior to initiating treatment in ART-naïve patients to determine whether they are infected with drug-resistant virus (genotypic testing); and 3) in patients experiencing virologic failure or incomplete viral suppression while receiving ART (genotypic and/or phenotypic testing). Most currently available assays require a viral load level of >500 to 1000 copies/mL for detection. For more information regarding resistance testing, refer to Section VI. B. HIV Resistance Assays in Antiretroviral Therapy.

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    B. Immunologic Assessment

    RECOMMENDATION:
    The CD4 lymphocyte profile should include both the absolute count and percentage. (I)

    A decline in absolute CD4 count may occur in some situations, such as after interferon therapy, when all lymphocyte populations are suppressed; however, the percentage of CD4 lymphocytes will remain relatively constant. A stable CD4 percentage generally indicates stable immune function even in the presence of declining absolute counts.

    Key Point:
    Routine quarterly monitoring of CD4 count is no longer recommended for nonpregnant patients receiving ART who have consistently undetectable HIV RNA levels and CD4 counts >200 cells/mm3 (for recommended intervals, see Antiretroviral Therapy, Section VI.A: Virologic and Immunologic Monitoring).


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    C. Tuberculosis Evaluation

    RECOMMENDATIONS:
    Clinicians should obtain a TST (tuberculin skin test, commonly known as PPD) or other FDA-approved test for diagnosis of latent tuberculosis infection, unless the patient has previously tested positive or has had previously documented TB. (I)

    After active tuberculosis has been excluded, clinicians should prescribe TB prophylaxis when a TST results in induration of ≥5 mm or when another FDA-approved test indicates the presence of latent TB infection. (I)

    Induration of ≥5 mm with a TST (tuberculin skin test, commonly known as PPD) is considered a positive reaction in the HIV-infected population and warrants prophylaxis. In general, anergy testing is no longer recommended.21 See Mycobacterial Infections.

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    D. Laboratory Screening for Sexually Transmitted Infections

    RECOMMENDATIONS:
    Clinicians should screen HIV-infected patients for syphilis by obtaining a non-treponemal test (RPR or VDRL) with verification of reactive test by confirmatory fluorescent treponemal antibody absorbance (FTA-Abs) or treponema pallidum particle agglutination (TP-PA) tests at baseline and at least annually. Patients with continued high-risk behavior should be screened for syphilis every 3 months.

    Clinicians should screen sexually active HIV-infected women under the age of 25 for gonorrhea and chlamydia at baseline and at least annually. Clinicians should screen all sites of possible exposure, including the cervix, rectum, and pharynx. Culture or nucleic acid amplification tests (NAT) should be used to screen for gonorrhea. Immunofluorescence or DNA amplification should be used for chlamydia.

    Clinicians should screen women 25 years of age or older for gonorrhea and chlamydia at baseline and at least annually if they have or have had a recent sexually transmitted infection, have multiple sexual partners, have had a new sexual partner, or have a sexual partner with symptoms of an STI.

    Clinicians should screen all HIV-infected men with ongoing high-risk sexual behaviors for gonorrhea and chlamydia at baseline and at least annually. Clinicians should screen all sites of possible exposure, including the urethra, rectum, and pharynx.

    Clinicians must report all suspected or confirmed syphilis, chancroid, gonococcal, and C trachomatis infections to the local health department of the area where the patient resides according to NYS requirements (also see Communicable Disease Reporting Requirements).

    The FTA-Abs and TP-PA confirmatory tests remain positive for life if there has been a history of syphilis infection. Some individuals previously treated for syphilis will continue to have a low serum antibody-positive RPR or VDRL. A 4-fold increase in RPR serum antibody indicates acute infection or re-infection with syphilis.

    Refer to Management of STIs in HIV-Infected Patients for more information about screening for STIs.

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    E. Cytologic Screening


    1. Cervical Pap Tests

    RECOMMENDATIONS:
    Clinicians should obtain cervical Pap tests for all HIV-infected women at baseline, 6 months after baseline, and then repeat annually, as long as results are normal.

    Colposcopy should be performed for women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis.

    Clinicians should repeat abnormal Pap tests every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with cervical HSIL also should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue.

    Clinicians should obtain at least an annual Pap test in HIV-infected women who have undergone either a supracervical or total hysterectomy.

    The purpose of cervical screening is to prevent the development of invasive cancer by identifying and treating individuals with precursor lesions that are at risk for progression to cancer. Widespread screening of all women with cervical cytology or Pap tests has led to a decline in morbidity and mortality from cervical cancer. The benefit of screening and treatment protocols for cervical abnormalities in HIV-infected women is also well established. Although cervical cytology (Pap tests) has lower sensitivity compared to actual tissue histology, colposcopy with Pap tests has increased the effectiveness of the evaluation of women with HIV infection, particularly those women with a report of atypical squamous cells of undetermined significance (ASC-US) by delineating likely abnormal tissue for biopsy and histologic evaluation.22

    Recurrent dysplasia on the vaginal cuff can be seen in women with a history of cervical dysplasia, and both HIV and HPV infections increase the risk of vaginal intraepithelial neoplasia. Therefore, women who have undergone a hysterectomy should still receive annual Pap tests. For additional information, see Cervical Cancer and Dysplasia.

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    2. Anal Pap Tests

    RECOMMENDATIONS:
    Clinicians should obtain anal cytology at baseline and annually in the following HIV-infected populations:

    • Men who have sex with men
    • Any patient with a history of anogenital condylomas
    • Women with abnormal cervical/vulvar histology

    Clinicians should refer patients with abnormal anal cytology for high-resolution anoscopy and/or examination with biopsy of abnormal tissue. (III)

    Like cervical cancer, invasive squamous cell cancers of the anal canal are associated with certain types of human papillomavirus (HPV) infection, most notably, HPV-16 and HPV-18. Although this is a new practice that may not be routinely available, screening for cellular dysplasia is prudent and recommended, particularly in persons at high risk for infection with papilloma viruses. For additional information, see Anal Dysplasia and Cancer.

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    V. HEALTH PROMOTION AND BEHAVIORAL HEALTH COUNSELING

    Updated March 2007

    RECOMMENDATION:
    Clinicians should provide routine HIV risk-reduction counseling and behavioral health counseling for HIV-infected patients (see Table 4). (I)

    Patients’ behaviors change over time as the course of their disease changes and their social situations vary. The clinician will need to tailor routine risk-reduction counseling and behavioral health counseling not only to the individual patient but also to the particular point in time in the patient’s life.23

    Table 4: Health Promotion and Behavioral Health Counseling
    Safer-sex practices
    • Partner notification
    • Latex and polyurethane barriers
    • Behaviors that carry transmission risk and those that do not
    Substance use counseling
    • Counseling if indicated based on assessment
        • Brief interventions and/or motivational interviewing*
        • Harm-reduction counseling
        • Referral for treatment
      • For injection drug users
        • Safe injection practices
        • Safe disposal of sharps
        • Access to sterile injecting equipment
    Tobacco use
    • Smoking cessation education
    Reproductive health counseling
    • Family planning
    • Options for the HIV-infected pregnant women
    • HIV transmission prevention
    • Risk of HIV transmission through breastfeeding24
    Psychosocial assessment
    • Housing status
    • Employment and insurance
    • Educational level
    • Family and partner contacts
    • Stability of personal relationships
      • Domestic violence screening
    • Legal issues
      • Living will and healthcare proxy
      • Permanency planning for dependent children
    Diet and exercise
    • Nutrition and exercise counseling
    • Diabetes and lipid abnormality counseling
    * For a detailed discussion regarding brief interventions, motivational interviewing, and harm reduction for patients who are actively using alcohol or other substances, see the Working With the Active User.

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    A. Safer Sex Education

    RECOMMENDATIONS:
    Clinicians should discuss safer sexual practices with HIV-infected patients on a routine and ongoing basis. (I)

    Clinicians should routinely discuss with patients the importance of disclosure to partners. Patients should be educated about the options for voluntary partner notification. These discussions should be clearly documented. Information about HIV reporting and partner notification in New York State is available at Provider Reporting & Partner Services. (I)

    Clinicians should emphasize that transmission of HIV may occur during unprotected sex, even when patients have undetectable HIV plasma viral loads. (I)

    Clinicians should recommend the correct and consistent use of latex or, when latex allergies exist, polyurethane male condoms and should discuss the option of using polyurethane female condoms. (I)

    Clinicians should instruct patients in the proper use of condoms, dental dams, and other barriers to reduce the risk of HIV transmission. (I)

    Clinicians should educate their patients to avoid using condoms and creams containing nonoxynol-9. (I)

    For patients who are sexually active, discussion should include a review of safer practices to prevent the transmission of HIV or other STIs. It is important to note that risk for transmission of HIV is increased in the setting of STIs, underscoring the importance of correct and consistent use of barrier protection during vaginal, rectal, or oral intercourse. Patients should be informed that because condoms do not cover all exposed areas, they are more effective in preventing infections transmitted by fluids from mucosal surfaces than in preventing infections transmitted by skin-to-skin contact.

    The use of both male and female condoms among patients should be encouraged, despite adverse attitudes toward them in some communities. Condoms should be offered along with instructions, support, counseling, and referral to community-based organizations.

    Clinicians should also inform patients that condoms containing nonoxynol-9, a topical spermicide used to prevent conception, should be avoided. In at least one large placebo-controlled study of sex workers using nonoxynol-9, there was an increase in new HIV infection.25

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    B. Substance Use Counseling

    RECOMMENDATIONS:
    When current alcohol or other substance use is identified, clinicians should discuss the possible effects of such use on the patient’s general health and HIV medications, as well as options for treatment if indicated. These discussions should be properly documented in the patient’s chart. (I)

    Clinicians should evaluate for possible interactions among illicit drugs and prescription drugs. (I)

    Clinicians should issue prescriptions for new needles and syringes to patients who inject drugs.

    Clinicians should discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Program and Syringe Exchange Programs, New York State’s two syringe access initiatives. (I)

    Clinicians should collaborate with social work staff and other mental health providers, when available, to determine which treatment programs or substance use services best meet the patient’s needs. (I)

    The HIV and Substance Use Guidelines contain information on the management of HIV-infected substance users. For specific information regarding interactions between illicit drugs and prescription drugs, refer to Drug-Drug Interactions Between Antiretroviral Agents, Medications Used in Substance Use Treatment, and Recreational Drugs.

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    C. Tobacco Use Assessment and Counseling

    RECOMMENDATION:
    Clinicians should assess smoking status and should encourage those who smoke to stop (I). Pharmacotherapy and referrals to smoking cessation programs should be provided if the patient is interested.

    Smoking increases a patient’s risk of developing thrush, cryptococcal meningitis, bacterial pneumonias, and coronary artery disease. In addition, HIV infection further increases the risk of lung and other cancers associated with smoking.

    Smoking cessation interventions delivered during routine visits will reach many smokers who are already receiving care for their HIV infection. Patients who are interested in quitting smoking within the next month should be helped to set a quit date, offered pharmacotherapy with nicotine replacement or bupropion, and referred to a counseling program. For further guidance on smoking cessation, refer to Smoking Cessation in HIV-Infected Patients.

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    D. Reproductive Counseling

    RECOMMENDATION:
    Clinicians should discuss family planning with patients, including risks to the mother and fetus during pregnancy.

    Many patients have questions about having children even though they or their partners are infected with HIV. Risks to the mother and fetus, as well as the risk of HIV transmission through breastfeeding,24 should be discussed. Alternative or supplemental family planning methods beyond condom use may also be addressed.

    For additional information, refer to the Women’s Health Guidelines: Preconception Care for HIV-Infected Women.

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    E. Domestic Violence

    RECOMMENDATIONS:
    Clinicians or a member of the healthcare team should screen all male and female HIV-infected patients for current and lifetime domestic violence at baseline and annually. (I)

    Prior to screening patients for domestic violence, clinicians should discuss confidentiality and exceptions to confidentiality, including instances of suspected child abuse and maltreatment and intent to harm self or others.

    Domestic violence screening should be performed only when the patient is alone.

    When real or potential domestic violence is recognized, social work services should be involved and referrals should be made to domestic violence organizations or domestic violence counseling. In the absence of social work services, clinicians should be familiar with resources available in the community and mechanisms of referral.

    The following are questions that may be used for screening:

    1. Do you ever feel unsafe at home?
    2. Are you in a relationship in which you have been physically hurt or felt threatened?
    3. Have you ever been or are you currently concerned about harming your partner or someone close to you?

    Other questions regarding sexual abuse, such as forced sexual activity, coercion, etc., may be applicable depending on the case.

    For more information regarding assessment for domestic violence, refer to the New York State Office for the Prevention of Domestic Violence, available at: http://www.opdv.ny.gov/

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    F. Psychosocial Assessment

    RECOMMENDATIONS:
    The clinician or a member of the healthcare team should perform a psychosocial assessment of HIV-infected patients, including housing status, at baseline and at least annually. (I)

    The clinician should work with the patient’s case manager to provide necessary medical guidance related to psychosocial issues that are potential barriers to treatment adherence. (I)

    When case managers are unavailable, clinicians will need to be able to refer their patients to social workers who can provide psychosocial services and facilitate referrals to supportive services. See Table 4 for elements of a psychosocial assessment.

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    G. Diet and Exercise Counseling

    Diet and exercise counseling can enhance the management of and the patient’s knowledge about the risks associated with diabetes, hypertension, problems associated with lipid abnormalities, and potential side effects of medications.

    For more information regarding nutrition among HIV-infected patients, refer to General Nutrition, Weight Loss, and Wasting Syndrome.

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    VI. PREVENTIVE MEDICINE

    Updated March 2011

    A. Standard Health Maintenance

    RECOMMENDATIONS:
    Clinicians should discuss general preventive healthcare and health maintenance with all HIV-infected patients routinely and, at a minimum, annually. (I)

    Clinicians should perform standardized age- and sex-appropriate health-maintenance interventions, such as cancer screening, in HIV-infected patients according to the same guidelines used for non-HIV-infected patients (see Table 5). (I)

    Clinicians should instruct patients on how to perform breast and testicular self-examinations. (III)

    Table 5: Age-Appropriate Diagnostic Screening
    • Mammogram
      • Annually for women aged ≥40
    • Prostate-specific antigen (PSA)
      • Annually, with digital rectal exam, for men aged ≥50 with at least a 10-year life expectancy
      • Annually for men aged ≥45 who are African American or who have a father, brother, or son who was diagnosed with prostate cancer at a young age
    • Colorectal cancer screena
      • Screen at age ≥50b
        • Colonoscopy every 10 years
          or
        • Annual fecal occult blood testing (FOBT) with flexible sigmoidoscopy every 5 years
          or
        • Annual FOBT and double-contrast barium enema every 5 years
    a Although the optimal screening strategy has not been established, one of the colorectal cancer screens listed above should be used.
    b Screening African Americans at age ≥45 may be advisable. African Americans have a younger mean age of onset of colorectal cancer and a greater incidence of cancerous lesions in the proximal large bowel.26



    Colorectal Cancer

    Colorectal cancer is the second leading cause of cancer death in the United States. According to the United States Preventive Services Task Force, universal screening for colorectal cancer in the general population should begin at age 50 in the absence of specific risk factors, such as previous colorectal cancer, strong family history, familial polyposis, or inflammatory bowel disease. Some data support screening African Americans aged ≥45 because they have a younger mean age of onset of colorectal cancer compared with other groups and a greater incidence of cancerous lesions in the proximal large bowel.26

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    B. Opportunistic Infection Prophylaxis

    RECOMMENDATION:
    Clinicians should initiate prophylaxis for specific opportunistic infections as indicated in Table 6 and discontinue it as indicated in Table 7. (I)

    Prophylaxis for opportunistic infections may be withdrawn for patients who are on effective ART and who have evidence of recovery of immunologic competence.

    Table 6: Initiation of Primary OI Prophylaxisa
    Pathogen Initiate Prophylaxis Preferred Agent Alternative Agents
    Pneumocystis jirovecii pneumoniab CD4 <200 cells/mm3 or <14% or a history of oropharyngeal candidiasis TMP/SMX
    qd or 3x/week
    • Dapsonec
    • Dapsonec + pyrimethamine + leucovorin
    • Atovaquone
    • Aerosolized pentamidine
    Mycobacterium avium complex (MAC) CD4 <50 cells/mm3 Azithromycin
    Clarithromycin
    • Rifabutin
    • Azithromycin + rifabutin
    Toxoplasma encephalitis (TE) CD4 <100 cells/mm3

    and

    Positive serology for Toxoplasma (IgG+)

    TMP/SMX qd • Dapsonec + pyrimethamine +
    leucovorin
    • Atovaquone with or without
    pyrimethamine + leucovorin
    Cytomegalovirus (CMV) Not routinely recommended NA NA
    Cryptococcus neoformans Not routinely recommended NA NA
    Candida Not routinely recommended NA NA
    a For information regarding prophylaxis treatment for patients with a TST test result of >5 mm induration or patients with close exposure to a known case of tuberculosis, please refer to Mycobacterial Infections.
    b Formerly Pneumocystis carinii.
    c Screen for G6PD deficiency before initiating dapsone.


    Table 7: Discontinuation of OI Prophylaxis
    Pathogen Discontinuation of Primary Prophylaxis Discontinuation of Secondary Prophylaxis
    Pneumocystis jirovecii pneumonia (PCP) Patient receiving ART with increase in CD4 to >200 cells/mm3 for ≥3 months • CD4 count >200 cells/mm3 for ≥3 months in response to ART
    • Adequate viral suppression
    • If PCP occurred with CD4 >200 cells/mm3, prophylaxis should be maintained
    Toxoplasma encephalitis (TE)a Patient receiving ART with increase in CD4 to >200 cells/mm3 for ≥3 months • CD4 >200 cells/mm3 for ≥6 months in response to ART
    • Completed initial therapy
    • Asymptomatic for TE
    Mycobacterium avium complex (MAC) CD4 increase to >100 cells/mm3 for ≥3 months in response to ART • CD4 increase to >100 cells/mm3 for ≥6 months in response to ART
    • Completed at least 12 months of treatment for disseminated MACb
    • Asymptomatic for MAC
    Cryptococcosis NA • CD4 increase to >100 to 200 cells/mm3 for ≥6 months
    • Completed initial therapy
    • Asymptomatic for cryptococcosis
    Cytomegalovirus (CMV) NA • CD4 >100 to 150 cells/mm3 for ≥6 months
    • No evidence of active disease
    • Regular ophthalmologic examination
    a HIV-infected adults or adolescents with a history of toxoplasmosis in childhood should be administered lifelong prophylaxis to prevent recurrence.
    b Obtaining blood cultures or bone marrow cultures may be advisable to ascertain disease activity.

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    C. Immunizations

    Updated March 2011 — The immunizations information in this section is outdated and currently under revision. Please check back for updates.

    Immunizations against infectious diseases are an extremely important component of care for patients with immune suppression. Concerns regarding vaccinations in HIV-infected individuals include:

    • The potential danger from live virus vaccines
    • The ability of HIV-infected patients to mount an appropriate immune response to vaccine

    In general, the more intact the immune system is, the more effective and safe the vaccines are. The use of live virus vaccines is generally undertaken when an inactivated version does not exist and when the risk of the disease clearly outweighs the theoretical risk of vaccination. Table 8 contains recommended immunizations for HIV-infected adults.

    2014 Health Alert:
    See New York State Department of Health recommendations for information regarding vaccination against meningococcal disease for men who have sex with men.


    Table 8: Recommended Immunizations for Nonpregnant HIV-Infected Adults
    Vaccine Indications Schedule
    Tetanus, Diphtheria, and
    Pertussis (Tdap),*
    and
    Tetanus-Diphtheria (Td)*
    For patients who have not received the primary series or for whom vaccine status is unknown Administer a one-time dose of Tdap, followed by a dose of Td at 1 month and a second dose of Td 6-12 months later

    Administer 1 dose of Td booster every 10 years

    For patients who have already received the primary series that did not include Tdap
    • Administer one-time dose of Tdap instead of Td booster if the last dose of Td was received ≥10 years ago
    • Intervals shorter than 10 years since the last Td may be used for booster protection against pertussis
    • After one-time dose of Tdap, administer 1 dose of Td booster every 10 years
    Influenza For all patients Administer 1 annual dose. Do not use FluMist because it contains live virus.
    Pneumococcal polysaccharide For all patients Administer 1 dose followed by one revaccination after 5 to 6 years (or more) have elapsed since initial vaccination
    Hepatitis A* All HIV-infected patients who are negative for HAV IgG Administer 2 doses
    (0 and 6-12 months)
    Hepatitis B* For patients without serologic evidence of prior HBV infection or who have not previously received the complete series of HBV vaccination Strongly encourage the vaccine series—3 doses
    (0, 1 to 2, and 6 months)
    Measles, Mumps, Rubella (MMR)* For all asymptomatic HIV-infected patients who do not have evidence of severe immunosuppression and who are seronegative for antibody to MMR Administer 1 dose
    For patients with severe immunosuppression (<200 cells/mm3) Do not administer vaccine
    Human Papillomavirus (HPV) For women between the ages of 9 and 26 years Administer 3 doses
    (at 0, 2, and 6 months)
    Varicella* For persons who are susceptible Consider administering 2 doses
    (at 0 and 4-8 weeks)
    For other vaccines, see CDC recommendations. Available at: www.cdc.gov/vaccines/
    * Covered by the Vaccine Injury Compensation Program. For information on how to file a claim, call 1-800-338-2382, or visit www.hrsa.gov/vaccinecompensation. To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005, 1-202-219-9657.
    Tetanus, Diphtheria, and Pertussis: Adults who have not previously received Tdap and who anticipate having close contact with an infant aged <12 months (e.g., parents; grandparents; childcare providers, and healthcare personnel) should receive a single dose of Tdap as soon as possible to reduce the risk for transmitting pertussis. An interval as short as 2 years from the last Td is suggested; shorter intervals can be used. When possible, women should receive Tdap before becoming pregnant. In persons aged ≥65 years who have not previously received Tdap and anticipate having close contact with an infant aged less than 12 months, a single dose of Tdap vaccine is recommended instead of Td vaccine. From MMWR 2011;60(01):13-15. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm
    Influenza: MMWR Recomm Rep 2002;51(RR-3):1-31. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5103a1.htm
    Pneumococcal: Vaccination effectiveness improves when CD4 count is >200 cells/mm3. (MMWR 1997;46[RR-8]:1-24; available at: www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm). The Infectious Diseases Society of America recommends administering to patients with CD4 counts >200 cells/mm3 (Clin Infect Dis 2009;49:651-681).
    Hepatitis A: Persons at higher risk for HAV infection should receive postvaccination antibody testing to verify vaccine efficacy and to identify patients who might benefit from vaccine boosting. Patients at higher risk include those with chronic liver disease (e.g. hepatitis B or C); men who have sex with men; travelers to countries with high endemicity of infection; persons who live in a community experiencing an outbreak of HAV infection; illicit drug users, particularly injection drug users; persons who have clotting-factor disorders; persons at occupational risk for infection. For persons who are susceptible to both hepatitis A and hepatitis B, the combined hepatitis A and B vaccine can be used: 3 doses at 0, 1, and 6 months.
    Hepatitis B: For persons who are susceptible to both hepatitis A and hepatitis B, the combined hepatitis A and B vaccine can be used: 3 doses at 0, 1, and 6 months.
    MMR: Measles component: Adults born before 1957 may be considered immune to measles. Adults born after 1957 should receive at least one dose of MMR unless they are severely immunosuppressed, [MMWR 1998;47(RR-8):1-57. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm], or there is documentation of at least one dose or other acceptable evidence of immunity (e.g., titers). A second dose of MMR is recommended for adults who were recently exposed to measles or in an outbreak setting; were previously vaccinated with killed measles vaccine; were vaccinated with an unknown vaccine between 1963 and 1967; are students in post-secondary educational institutions; work in healthcare facilities; plan to travel internationally. Foreign-born patients who have never received the vaccine should receive the full series. Consider administering 2 doses to persons with occupational, geographic, or other risk (optional). (Recommended Immunizations for Adults with Medical Conditions; Recommendations of the Advisory Committee on Immunization Practices, CDC, October 2002.)
    Mumps component: 1 dose of MMR should be adequate for protection. (Recommended Immunizations for Adults with Medical Conditions; Recommendations of the Advisory Committee on Immunization Practices, CDC, October 2002.)
    HPV: Protects against HPV types 6, 11, 16, and 18. HPV testing is not required before administration of the vaccine. The vaccine has been demonstrated to produce high levels of neutralizing antibody for 5 years. HPV vaccine is most effective in women who are not yet sexually active. However, most women, regardless of whether they are sexually active, may benefit from vaccination. In clinical trials, only 1 in 1,000 women showed evidence of exposure to all four types of HPV prevented by the vaccine. Gardasil may also provide some cross-protection against HPV genotypes other than 6, 11, 16, and 18. However, additional data are required before the vaccine can be recommended for the prevention of cross-reactive HPV types. Clinicians should continue to perform regular cervical screening with Pap tests and visual inspection of the vulva and vagina during annual pelvic examinations in women who have received the HPV vaccine. Most of the data regarding HPV vaccine safety and efficacy are derived from studies in non-HIV-infected females. Immune response to the vaccine may be decreased in the setting of HIV infection. Studies are currently underway to provide more extensive data regarding the safety and efficacy of the vaccine in the HIV-infected population. The Food and Drug Administration has approved the HPV vaccine Gardasil for use in boys and men 9 to 26 years of age. A recommendation regarding vaccination for HIV-infected boys and men is currently under consideration by the Committee for the Care of Children and Adolescents With HIV Infection and is not yet addressed in these guidelines.
    Varicella: Varicella vaccine may be considered for asymptomatic HIV-infected persons with CD4 percentages ≥25% and who do not have reliable clinical history of varicella infection, or serologic evidence of varicella zoster virus (VZV) infection. Note: Greater than 90% of US-born adults are immune to VZV.

    For more information regarding immunizations, including immunizations for pregnant HIV-infected women, refer to the Prevention of Secondary Diseases Guidelines.

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    VII. COORDINATION OF CARE

    Updated March 2007

    RECOMMENDATIONS:
    As part of the initial visit, the clinician or other member of the healthcare team should educate new patients about the following items (III):

    • How to access emergency services (provide a phone number for 24-hour services)
    • Whom to contact to schedule appointments
    • How to obtain laboratory and radiology results, medical records, and other reports

    After receiving patient consent, clinicians should share information with other agencies from which their patients are receiving services. (III)

    Case management should be used to enhance coordination of care provided by agencies such as home care, nutrition services, and nursing services and to prevent duplication of services. (III)

    Clinicians should regularly involve case managers in case conferences to discuss psychosocial issues that may affect a patient’s ability to adhere to care. (III)

    Comprehensive HIV care often involves multidisciplinary care with involvement of more than one provider. To facilitate adherence to all facets of care, the clinician should work with the case management team to coordinate medical care, referrals, and ongoing services in the community.

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    VIII. APPROPRIATE USE OF ACUTE CARE SERVICES

    Updated March 2007

    RECOMMENDATIONS:
    Outpatient clinicians who do not provide inpatient care should have a network of practitioners with whom they can communicate easily should their patients require hospitalization. (III)

    Inpatient clinicians should ensure that the details of hospitalization, including the discharge medications and plans, are sent in a timely fashion to outpatient clinicians. (III)

    Communication among practitioners is essential when patients move between primary care clinicians and other healthcare settings. When patients are referred to the emergency room, communication with the emergency room physician, both by phone and by transmission of essential data, such as pertinent medical conditions, the medication list, the patient’s most recent CD4 count and viral load, and any other pertinent clinical data, can improve the patient’s care and help prevent unnecessary testing or hospitalization. If the patient needs to be hospitalized and the primary care clinician is not the admitting physician, communication of these data to the admitting physician is essential.

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    IX. APPROPRIATE USE OF CHRONIC CARE SERVICES

    Updated March 2007

    Communication is essential between outpatient practitioners and all professionals involved in the patient’s care. This includes both nursing services and other consultants and ancillary providers such as physical therapists.

    A. AIDS Adult Day Health Care Program

    AIDS Adult Day Health Care Programs (ADHCs) are designed to assist in meeting the healthcare needs of patients with HIV/AIDS who require a greater range of comprehensive healthcare services than can be provided in any single ambulatory setting but who do not require the level of services provided in a hospital or skilled nursing facility. Through a therapeutic environment, ADHCs are intended to improve and stabilize the health of patients with HIV/AIDS, assist patients with adherence support, reduce hospital stays, eliminate unnecessary visits to primary care clinicians and emergency rooms, and provide interventions in the form of one-on-one counseling and structured group activities for substance use and mental health disorders. Nursing care, nutritional services, case management, and HIV risk reduction, as well as auricular acupuncture and therapeutic massage, are also provided. For more information on these programs, contact 1-518-474-8162.

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    B. Home Healthcare

    RECOMMENDATION:
    Home health nurses should be provided with a copy of the patient’s medication list and information regarding current medical conditions and mental health or substance use disorders. (III)

    Home care, including infusion therapy, can help maintain the patient’s health and reduce the need for hospitalization. AIDS Home Care Programs (AHCPs) ensure patients’ access to enhanced physician services, dental care, HIV prevention and education services, substance use and treatment services, pastoral care, mental health services, peer support, HIV clinical trials, and HIV therapies. AHCP services may be provided by a long-term home healthcare program or a Designated AIDS Center specifically authorized to provide these services.

    AHCPs are responsible for arranging and/or providing the following: nursing services, home health aide services, medical supplies, equipment and appliances, physical and occupational therapy, speech pathology, nutritional services, medical social services, personal care services, and housekeeping services. Long-term home healthcare programs may also provide personal emergency response, meals on wheels, housing improvement, home maintenance, moving assistance, social daycare, and social transportation services.

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    C. End-of-Life Care

    RECOMMENDATIONS:
    Clinicians should encourage patients to prepare an advanced directive and designate a healthcare proxy and should review these arrangements at least annually.

    As HIV disease progresses, clinicians should discuss patients’ feelings about end-of-life care before they are unable to make decisions. Any medical decisions that are made should be in conjunction with the patient, or, if the patient is unable to decide for neurologic reasons, with the patient’s healthcare proxy. (III)

    Clinicians should be familiar with hospice services available in their area and should make referrals to them early enough for the patient to receive the full benefit of their support (III). Clinicians should work in conjunction with hospice staff to establish which medical interventions may still be appropriate as quality of life evolves or changes. (III)

    End-stage HIV infection often involves a series of treatments for opportunistic infections, tumors, or other life-threatening comorbid conditions, such as liver failure. When both the patient and the clinician agree that aggressive care is no longer desired or likely to succeed, supportive care with a goal to maximize comfort is appropriate.

    Clinicians should work with hospice staff to establish which interventions may still be appropriate as quality of life declines. For example, continuing aggressive care of cytomegalovirus retinitis to prevent blindness is a treatment that may need to be continued even though the patient has elected to discontinue other active medications.

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    REFERENCES

    1. National Network of Libraries of Medicine. Health Literacy. Bethesda, Md. Available at: http://nnlm.gov/outreach/consumer/hlthlit.html

    2. Alambuya RN, Ali S, Apostolidis K, et al.; Salzburg Global Seminar. Salzburg statement on shared decision making. BMJ 2011;342:d1745. [PubMed]

    3. Bertz RJ, Persson A, Chung E, et al. Pharmacokinetics and pharmacodynamics of atazanavir-containing antiretroviral regimens, with or without ritonavir, in patients who are HIV-positive and treatment-naïve. Pharmacotherapy 2013;33:284-294. [PubMed]

    4. Rahmanian S, Wewers ME, Koletar S, et al. Cigarette smoking in the HIV-infected population. Proc Am Thorac Soc 2011;8:313-319. [PubMed]

    5. Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: A nationwide, population-based cohort study. Clin Infect Dis 2013;56:727-734. [PubMed]

    6. Sigel K, Wisnivesky J, Gordon, et al. HIV as an independent risk factor for incident lung cancer. AIDS 2012;26:1017-1025. [PubMed]

    7. Mani D, Haigentz M Jr, Aboulafia DM. Lung cancer in HIV infection. Clin Lung Cancer 2012;13:6-13. [PubMed]

    8. D’Jaen GA, Pantanowitz L, Bower M, et al. Human immunodeficiency virus-associated primary lung cancer in the era of highly active antiretroviral therapy: A multi-institutional collaboration. Clin Lung Cancer 2010;11:396-404. [PubMed]

    9. Zhang S, van Sighem A, Kesselring A, et al. Episodes of HIV viremia and the risk of non-AIDS diseases in patients on suppressive antiretroviral therapy. J Acquir Immune Defic Syndr 2012;60:265-272. [PubMed]

    10. Gordin F, Finley E, Dietz D, et al.; Strategies for Management of Antiretroviral Therapy (SMART) Study Group. Major clinical outcomes in antiretroviral therapy (ART)-naive participants and in those not receiving ART at baseline in the SMART study. J Infect Dis 2008;197:1133-1144. [PubMed]

    11. El-Sadr WM, Lundgren J, Neaton JD, et al.; Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med 2006;355:2283-2296. [PubMed]

    12. Phillips AN, Carr A, Neuhaus J, et al. Interruption of antiretroviral therapy and risk of cardiovascular disease in persons with HIV-1 infection: Exploratory analyses from the SMART trial. Antivir Ther 2008;13:177-187. [PubMed]

    13. Lichtenstein KA, Armon C, Buchacz K, et al. Low CD4+ T cell count is a risk factor for cardiovascular disease events in the HIV outpatient study. Clin Infect Dis 2010;51:435-447. [PubMed]

    14. Mocroft A, Phillips AN, Gatell J, et al. CD4 cell count and viral load-specific rates of AIDS, non-AIDS and deaths according to current antiretroviral use. AIDS 2013;27:907-918. [PubMed]

    15. Friis-Møller N, Thiébaut R, Reiss P, et al. Predicting the risk of cardiovascular disease in HIV-infected patients: The data collection on adverse effects of anti-HIV drugs study. Eur J Cardiovasc Prev Rehabil 2010;17:491-501. [PubMed]

    16. May M, Sterne JA, Shipley M, et al. A coronary heart disease risk model for predicting the effect of potent antiretroviral therapy in HIV-1 infected men. Int J Epidemiol 2007;36:1309-1318. [PubMed]

    17. Frerichs FC, Dingemans KP, Brinkman K. Cardiomyopathy with mitochondrial damage associated with nucleoside reverse-transcriptase inhibitors. N Engl J Med 2002;347:1895-1896. [PubMed]

    18. Arora S, Weber MA, Fox CJ, et al. Common femoral artery ligation and local debridement: A safe treatment for infected femoral artery pseudoaneurysms. J Vasc Surg 2001;33:990-993. [PubMed]

    19. Herreros-Villanueva M, Hijona E, Bañales JM, et al. Alcohol consumption on pancreatic diseases. World J Gastroenterol 2013;19:638-647. [PubMed]

    20. Palefsky J, Holly E, Ralston M, et al. Prevalence and risk factors for anal human papillomavirus infection in human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women. J Infect Dis 2001;183:383-391. [PubMed]

    21. Centers for Disease Control and Prevention. Anergy skin testing and tuberculosis preventive therapy for HIV-infected persons: Revised recommendations. MMWR Morb Mortal Wkly Rep 1997;46(RR-15):1-10. [PubMed]

    22. Franco EL, Duarte-Franco E, Ferenczy A. Cervical cancer: Epidemiology, prevention and the role of human papillomavirus infection. CMAJ 2001;164:1017-1025. [PubMed]

    23. Schreibman T, Friedland G. Human immunodeficiency virus infection prevention: Strategies for clinicians. Clin Infect Dis 2003;36:1171-1176. [PubMed]

    24. Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics 2013;131;391-396. [PubMed]

    25. Van Damme L, Ramjee G, Alary M, et al. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial. Lancet 2002;360:971-977 (Erratum in: Lancet 2002;360:1892). [PubMed]

    26. Agrawal S, Bhupinderjit A, Bhutani MS, et al.; for the Committee of Minority Affairs and Cultural Diversity, American College of Gastroenterology. Colorectal cancer in African Americans. Am J Gastroenterol 2005;100;515-523. [PubMed]

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    APPENDIX A: MEDICATION EVALUATION FORM

    Updated November 2014

    HIV Management 2015

    Click on image to download Appendix A: Medical Evaluation Form

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    APPENDIX B: DERMATOLOGIC AND RELATED COMPLICATIONS ASSOCIATED WITH HIV

    Updated November 2014

    Appendix B-1. Dorsocervical Fat Pad
    Appendix B-1. Dorsocervical Fat Pad
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credits: Dominic C. Chow, MD, University of Hawaii; Larry J. Day, MD, University of Michigan; Cecilia M. Shikuma, MD, University of Hawaii.

    Appendix B-2. Drug-Related Eruption
    Appendix B-2. Drug-Related Eruption
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-3. Folliculitis (Eosinophilic)
    Appendix B-3. Folliculitis (Eosinophilic)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-4. Herpes Simplex
    Appendix B-4. Herpes Simplex
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-5. Herpes Simplex (Genital)
    Appendix B-5. Herpes Simplex (Genital)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-6. Herpes Zoster (Shingles)
    Appendix B-6. Herpes Zoster (Shingles)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-7. Kaposi’s Sarcoma
    Appendix B-7. Kaposi’s Sarcoma
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-8. Lipoatrophy (Facial wasting: facial fat loss with deepening of nasolabial fold)
    Appendix B-8. Lipoatrophy (Facial wasting: facial fat loss with deepening of nasolabial fold)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credits: Dominic C. Chow, MD, University of Hawaii; Larry J. Day, MD, University of Michigan.

    Appendix B-9. Lipoatrophy (Wasting: Fat depletion of leg with prominence of veins and enhanced definition of musculature)
    Appendix B-9. Lipoatrophy (Wasting: Fat depletion of leg with prominence of veins and enhanced definition of musculature)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credits: Dominic C. Chow, MD, University of Hawaii; Larry J. Day, MD, University of Michigan; Cecilia M. Shikuma, MD, University of Hawaii.

    Appendix B-10. Molluscum Contagiosum
    Appendix B-10. Molluscum Contagiosum Appendix B-10. Molluscum Contagiosum
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Susanne Theresia Duerr, MD, University of Regensburg, Germany; provided courtesy of the Hôpital de Shyria, Rwanda. Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-11. Onychomycosis
    Appendix B-11. Onychomycosis
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-12. Psoriasis
    Appendix B-12. Psoriasis
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-13. Retinopathy (HIV-Related)
    Appendix B-13. Retinopathy (HIV-Related)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-14. Seborrheic Dermatitis
    Appendix B-14. Seborrheic Dermatitis Appendix B-14. Seborrheic Dermatitis
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-15. Tinea
    Appendix B-15. Tinea
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Paul A. Volberding, MD, University of California San Francisco.

    Appendix B-16. Vasculitis (Associated With HIV/HCV Co-Infection)
    Appendix B-16. Vasculitis (Associated With HIV/HCV Co-Infection)
    Source: US Department of Veterans Affairs, HIV/AIDS Image Library. Credit: Erin Huiras Amerson, MD, and Toby A. Maurer, MD, University of California San Francisco. Reproduced with permission from The International AIDS Society-USA [Top HIV Med 2010;18:16-22].


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