History, Assessment, and Evaluation: Initial, Ongoing, and Annual

History, Assessment, and Evaluation: Initial, Ongoing, and Annual

Lead authors: Mary Dyer, MD, and Christine Kerr, MD, with the  Medical Care Criteria CommitteeFebruary 2021

RECOMMENDATIONS
History, Assessment, and Evaluation

History-taking for patients with HIV requires attention to all of the elements standard in primary care while including several additional elements, which are detailed in Table 1: HIV, Medications, and General Medical Status and History for Adults With HIV and Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV. It is essential to identify, assess, and monitor HIV- and antiretroviral therapy (ART)-related complications and other HIV-specific comorbidities (see Box 1: Conditions With Higher Incidence in People With HIV and Selected Citations).

A comprehensive baseline history includes sexual health, mental health, substance use (including illicit use of prescription drugs), and social history. Patients may choose not to disclose all pertinent personal information during the first visit, but a sympathetic and nonjudgmental attitude can help establish trust and facilitate further discussion and disclosure during subsequent visits.

Anatomical inventory: In addition to all elements of a standard patient history and physical examination, it is important for clinicians to perform an anatomical inventory and determine primary care needs based on which organs are present rather than on the gender expression of the patient. A matter-of-fact anatomical inventory will identify present and absent organs: penis, testes, prostate, breasts, vagina, cervix, uterus, and ovaries.

HIV-Specific Medical History 

Essential components of an HIV-specific medical history are detailed below and in Table 1: HIV, Medications, and General Medical Status and History for Adults With HIV. Confirmation of a patient’s HIV infection should include documented laboratory testing results. If results are not available, baseline testing should be performed as noted in Table 1 (also see the NYSDOH AI guideline HIV Testing > Steps in the HIV Diagnostic Testing Algorithm). If a patient was recently diagnosed with HIV, discussion of the reasons for testing and the route of exposure will assist the clinician in identifying appropriate goals for risk reduction education, counseling, and intervention, which may include ongoing screening for sexually transmitted infections (STIs).

Essential components of a HIV-specific medical history:

  • Viral load and CD4 cell count at diagnosis, if known
  • Patient circumstances at time of diagnosis (housing, employment, food security, relationship status, etc.)
  • ART history, including previous regimens, reasons for any changes in prior regimens, and any adverse effects
  • Pauses in treatment and lapses in adherence
  • Previous resistance testing results
  • History of opportunistic infections
  • History of HIV-related hospitalization(s)
  • Disclosure status (whether partners, family, or friends are aware of HIV status) and partner notification
  • History of other STIs with shared risk factors, including hepatitis B virus (HBV) and hepatitis C virus (HCV)
  • Ongoing high-risk behaviors for transmission of HIV and acquisition of STIs or infections associated with injection drug use
  • Experience of stigma and social support

ART history: Essential elements of an ART history include all previous medications, why they were stopped, and reasons for stopping (e.g., allergies, adverse effects, pill-taking fatigue or discomfort, and resistance). Understanding these reasons and seeking ways to simplify ART regimens or reduce pill burden will support a therapeutic alliance around adherence going forward.

ART initiation: If a patient with HIV has not yet started ART, it should be initiated as soon as appropriate and possible, and any barriers to ART initiation should be assessed so support can be provided. For evidence-based recommendations, see the NYSDOH AI guideline When to Initiate ART, With Protocol for Rapid Initiation.

Trauma-informed care: A trauma-informed approach to care is important to mitigate any medical trauma, such as frightening experiences or stigma associated with the initial HIV diagnosis [Sherr, et al. 2011; Tang, et al. 2020]. See the following for more information:

Adherence: For patients already taking ART, assessing adherence and providing support for optimal adherence are crucial and should include careful assessment of adverse medication effects, which often lead to adherence problems or medication cessation. Other factors to discuss that may pose barriers to adherence include insurance coverage, housing instability, disclosure status, substance use, and mental health.

Viral hepatitis status: Many of the risk factors for acquisition of viral hepatitis are the same as those for HIV. Assessment of a patient’s viral hepatitis status, including a history of viral hepatitis infection and treatment, helps clinicians determine optimal treatment options. In individuals with HIV, progression of HBV- or HCV-associated liver fibrosis, cirrhosis, cancer, portal hypertension, and encephalopathy is more rapid than in those without HIV [Benhamou, et al. 1999; Graham, et al. 2001; Thio, et al. 2002; Weber, et al. 2006].

HCV: Because the risk of severe liver disease is increased in patients with HIV [Soti, et al. 2018], all patients with HCV and HIV should be treated for HCV infection as soon as possible. Potential interactions between ART and HCV medications should be identified and addressed. Treatment of chronic HCV is the same for individuals with and without HIV.

HBV: A history of HBV infection will influence HIV medication choice and requires attention to drug-drug interactions. Because tenofovir, emtricitabine, and lamivudine are effective against both HBV and HIV, it is important to assess baseline HBV status and choose combination HIV therapy to appropriately treat the HBV infection as well as HIV. It is also important to appropriately monitor for progression of fibrosis or hepatocellular carcinoma; however, ART initiation should not be delayed pending evaluation of HBV status and liver damage.

General Medical Status, History, and Physical Examination

This guideline assumes that care providers are familiar with performing a comprehensive physical examination. Several areas may require additional attention because the incidence, associated complications, or severity may be increased in individuals with HIV or low CD4 cell counts.

Medications: Ideally, a complete medication history should be acquired at baseline and updated as needed during future visits. A detailed medication history (with emphasis on ART) allows the clinician to identify possible adverse drug-drug interactions between ART and medications the patient is taking to treat comorbidities (see Box 1: Conditions With Higher Incidence in People With HIV and Selected Citations). Patients with HIV may have multiple comorbidities due to infection and related inflammatory processes or the effects of medications. Examination of a patient’s current medical status and medication regimen may identify the need for changes in the ART regimen, changes in medications prescribed for other medical conditions, options for simplification of medication regimens, and medications that may be discontinued. See the NYSDOH AI guideline Selecting an Initial ART Regimen > Special Considerations for Comorbid Conditions.

Selected Resources for Information on ART Drug-Drug Interactions

Metabolic changes: There are significant metabolic concerns for people with HIV and AIDS [Mankal and Kotler 2014]. Weight gain often occurs after initiation of ART. Assessing weight loss or gain at every visit will assist with early identification of metabolic changes [Bourgi, et al. 2020]. Female gender, Black race, pre-ART CD4 cell count depletion, and lower pre-ART body mass index have been associated with >10% weight gain at 2 years post-ART initiation [Bourgi, et al. 2020]. Integrase strand transfer inhibitors (dolutegravir, bictegravir, raltegravir, elvitegravir, and cabotegravir) have been associated with greater weight gain than nonnucleoside reverse transcriptase inhibitors or protease inhibitors, particularly when used in combination with tenofovir alafenamide [Sax, et al. 2020]. Weight loss is more common in individuals with low CD4 cell counts and may prompt investigation of malignancy, infection, and psychosocial instability.

Head, eyes, ears, nose, and throat: An ophthalmologic examination at baseline and at least annually thereafter is indicated for patients with a CD4 count <50 cells/mm3. Cytomegalovirus (CMV) infection can lead to retinitis, vision loss, and death. Varicella zoster virus and herpesvirus infections can lead to retinitis and retinal necrosis [Nakamoto, et al. 2004]. After the introduction of highly active ART, the 10-year cumulative incidence for CMV retinitis was 33.6% for individuals with CD4 counts <50 cells/mm3 and 4.2% for those with CD4 counts <200 cells/mm3 [Sugar, et al. 2012]. Icterus may be present in individuals who are taking atazanavir as part of their ART regimen by causing a benign hyperbilirubinemia [Bertz, et al. 2013]. HIV viremia can also lead to a direct retinopathy at high viral loads and low CD4 cell counts [Jabs 1995].

Although HIV infection itself does not increase the likelihood of viral upper respiratory infections, symptoms such as cough, sinusitis, and otitis are common in patients with HIV [Small and Rosenstreich 1997; Brown, et al. 2017; Chiarella and Grammer 2017]. Because sinusitis and otitis can present without significant facial pain or discomfort in patients with CD4 counts <50 cells/mm3, it is reasonable to perform imaging and evaluate for infection with atypical organisms, such as fungal sinusitis, more readily in these patients.

People with HIV also have a higher risk of oral malignancies than those without HIV, and those with low CD4 cell counts may have diverse oropharyngeal findings, including oral Kaposi’s sarcoma, oral candidiasis, human papillomavirus (HPV)- and HIV-related parotitis, necrotizing gingivitis, requiring evaluation during in-person examinations [Epstein 2007; Sorensen 2011; Trevillyan, et al. 2018]. Clinicians should encourage patients to have annual dental examinations (see NIH > NIDCR > HIV/AIDS & Oral Health).

Heme/lymph: Lymphadenopathy may occur at any stage of HIV disease, does not always correlate with disease progression or prognosis, and may be less pronounced in older patients. However, widespread, firm, or asymmetrical lymphadenopathy requires prompt consideration of lymphoma, syphilis, tuberculosis, mycobacterium avium-intracellulare infection, and lymphogranuloma venereum, all of which can occur regardless of CD4 cell count, although more likely at lower CD4 cell counts. Nonadherence to ART may also be considered.

Diffuse large B-cell lymphoma, Burkitt lymphoma, and primary central nervous system lymphoma are AIDS-defining conditions; lymphoproliferative diseases, such as Castleman disease, should be considered as well. Any evidence of lymph nodes larger than 1 cm or evidence of fixed, matted, or hard nodes should prompt consideration for biopsy, particularly if a patient has a low CD4 cell count.

Dermatologic: An annual comprehensive skin examination will ensure that concerns are identified early. Regardless of CD4 cell count, findings such as shingles and psoriasis are seen more frequently in people with HIV than in those without HIV [Erdmann, et al. 2018; Alpalhão, et al. 2019].

Attention should be paid to any dermatologic history, such as a history of skin cancers and recurrent rash, which could be consistent with psoriasis, seborrheic dermatitis, atopic dermatitis, eosinophilic folliculitis, or secondary syphilis [Green, et al. 1996; Alpalhão, et al. 2019]. Symptoms can overlap and coexist.

Less common diseases, such as Kaposi sarcoma, eosinophilic folliculitis, disseminated zoster, molluscum contagiosum, and cutaneous HPV, may occur in patients with low CD4 cell counts. Familiarity with these diseases is important.

Neurologic: As noted in Table 1, clinicians should perform a neurologic and cognitive function examination in all patients at baseline, at least annually for those at risk (due to low CD4 cell count, age, or comorbidities) and more often if there are patient or family concerns. Several standardized tests are available, including the MoCA Test (requires an account), Mini-Cog, and Standardized Mini-Mental State Examination (SMMSE).

Compared with patients who have higher CD4 cell counts, patients with low CD4 cell counts may be at increased risk for neurologic conditions, which can include rare diseases, such as progressive multifocal leukoencephalopathy, HIV-associated neurologic disease, toxoplasmosis, and cryptococcal meningitis, and common diseases with atypical presentation, such as syphilis and tuberculosis.

In a patient with a low CD4 cell count or new or persistent symptoms regardless of CD4 cell count, neurologic symptoms, such as seizure, changes in mental status, or persistent headache, warrant imaging and diagnostic work-up.

Respiratory: Clinicians should perform a lung examination at baseline and at least annually, or more often if indicated. Community-acquired pneumonia is more common in people with HIV, regardless of CD4 cell count, than in those without HIV [Almeida and Boattini 2017], as is chronic obstructive pulmonary disease [Bigna, et al. 2018]. Chronic lung disease is increasingly common among older people with HIV, among smokers, and among those who have survived Pneumocystis jiroveci pneumonia (PJP; formerly known as Pneumocystis carinii pneumonia or PCP), who may have residual blebs that can lead to pneumothorax [Risso, et al. 2017].

In patients with low CD4 cell counts who have respiratory examination findings or symptoms, clinicians should perform a chest radiographic or computerized tomography to evaluate for infection or neoplasm [Yee, et al. 2020]. Clinicians should also maintain a low threshold for suspicion of tuberculosis (TB) and pursue appropriate diagnostic and public health measures if TB is suspected.

Comorbidities: For patients with comorbidities, such as cardiovascular disease, lung disease, renal disease, diabetes mellitus, and malignancies, personal and family history should be collected, and individual risk factors should be discussed. Because HIV has been associated with increased risk and accelerated disease process for these comorbidities, care providers should be sure to discuss appropriate screening and have a low threshold for diagnostic testing referral if symptoms develop [Crothers, et al. 2006; Bower, et al. 2009; Shiels, et al. 2011; Islam, et al. 2012; Triant 2013; Kaspar and Sterling 2017]. In individuals taking ART, risk factors such as smoking and hypertension cause more morbidity and mortality than HIV-specific risk factors, such as low CD4 cell count [Helleberg, et al. 2015; Trickey, et al. 2016; Althoff, et al. 2019].

History of particular comorbidities may also influence medication choice for those starting ART (see the NYSDOH AI guideline Selecting an Initial Antiretroviral Regimen). For example, patients with a history of metabolic disease may wish to avoid protease inhibitors due to the association with central obesity, and patients with risk factors for significant renal disease may wish to avoid tenofovir disoproxil fumarate. If patients do have significant risk for these conditions and are taking ART or other medications that can affect them, more frequent monitoring may be warranted [Crum-Cianflone, et al. 2010]. Nonalcoholic steatohepatitis is 30% to 40% more common in people with HIV [Kaspar and Sterling 2017] and may affect both monitoring and medication choice.

Endocrine conditions, such as metabolic syndrome, insulin resistance, dyslipidemia, lipodystrophy, and osteoporosis, may be worsened by certain antiretroviral medications. A full medication history will help clinicians identify the possibility of ART-associated contribution to these conditions [Gazzaruso, et al. 2003; Noubissi, et al. 2018]. Because thyroid disease and hypogonadism occur more often in people with HIV than in those without, a low threshold for screening for these conditions is appropriate.

Aging: As the population living with HIV ages, frailty, functional, and cognitive assessments are essential. Baseline discussion of memory loss, neuropathic symptoms, and chronic pain can help identify conditions that may affect ART adherence. Nadir CD4 cell count is a predictor of cognitive impairment and disorders [Ellis, et al. 2011]. Collecting structured data through use of standardized assessments will help clinicians to determine illness course; standardized assessment tools include the MoCA Test (requires an account), Mini-Cog, or Standardized Mini-Mental State Examination (SMMSE). An annual assessment of functional status is also indicated. For more information, see the NYSDOH AI Guidance for Addressing the Needs of Older Patients in HIV Care.

Psychosocial status: Baseline and annual psychosocial assessments, as described in Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV, include a detailed sexual, trauma, substance use, and psychiatric history; more frequent assessment may be required for patients who require follow-up in any area. Care providers, particularly those new to HIV care, may initially feel uncomfortable conducting these assessments. Resources are provided below for structured assessments; a team approach when possible may be helpful and allow for incorporation of multidisciplinary assessments, including those of a case manager and clinical social worker.

Sexual health: Discussion of sexual health, including a patient’s history of STIs, is an important component of the baseline and annual assessments and is an opportunity to discuss a patient’s concerns and questions. The frequency of the sexual health assessment is based on risk factors. It is particularly important to use nonjudgmental, sex-positive language in this discussion to establish a strong connection and facilitate open discussion. Discussion of U=U (Undetectable = Untransmittable) in the clinical setting can facilitate reduction of stigma and discussion of important considerations in sexual health.

Reproductive status: Clinicians should ascertain reproductive history and goals with all patients and address contraception and plans for conception with patients of childbearing potential. Patients wishing to have children should be supported and provided with information on current strategies to eliminate perinatal HIV transmission. Risk of perinatal transmission is less than 1% when patients are virally suppressed and with informed management of the perinatal period [Ioannidis, et al. 2001]. For patients who are pregnant or planning pregnancy, care providers should discuss appropriate preconception planning, including folate use, medication safety, and plans for breastfeeding, as well as the risk to a partner without HIV if the patient has a detectable viral load. Education about HIV pre-exposure prophylaxis should be provided when indicated (see the NYSDOH AI guideline PrEP to Prevent HIV and Promote Sexual Health).

Menopause, whether natural or surgical, has been associated with increased fatigue and muscle aches or pains in people with HIV [Schnall, et al. 2018].

Laboratory and Diagnostic Testing

Recommended laboratory testing is outlined in Table 3: Recommended Laboratory Testing for Adults With HIV.

References

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Table 1: HIV, Medications, and General Medical Status and History for Adults With HIV

Lead authors: Mary Dyer, MD, and Christine Kerr, MD, with the  Medical Care Criteria CommitteeFebruary 2021

Download Table 1 PDF

Guide to the tables: Although the tables are comprehensive in scope, this committee supports a flexible approach in using this guide to elements that should be included in a comprehensive initial history and physical. All aspects of the patient history and physical examination do not have to be covered in a single visit or by the primary care clinician per se. For some care providers and patients, the best approach may be to spend 2 or more visits completing the initial assessment and address some aspects of the history and physical during follow-up visits.

Table 1: HIV, Medications, and General Medical Status and History for Adults With HIV
*Frequency Key: I = initial (baseline) visit; A = annual visit; E = every visit

Assessment To Include Frequency*
I A E
Current HIV-Specific Status and History
HIV I    
Antiretroviral therapy
  • Date of ART initiation
  • Current ART regimen
  • Previous ART regimens and reasons for any changes in regimens
  • History of drug resistance, if known
  • Adverse effects
  • Current adherence status and challenges
  • Knowledge of Undetectable = Untransmittable, see NYSDOH AI U=U Guidance for Implementation in Clinical Settings

⇒ If ART has not been initiated, see the NYSDOH AI guideline When to Initiate ART, With Protocol for Rapid Initiation.

I A  
Viral load
  • Most recent viral load
  • Peak viral load
I A  
CD4 cell count
  • Most recent CD4 cell count
  • Nadir CD4 cell count
I A  
AIDS-defining conditions
  • Previous diagnoses and treatments
  • History of malignancies and treatments
  • Investigation of symptoms such as weight loss, night sweats, or chronic cough
I    
Opportunistic infections
  • Previous OI prophylaxis
  • Previous diagnoses and treatment, including latent TB infection
  • Adverse reactions to medications for OI prophylaxis or treatment
I    
Current Medications
Complete medication list
  • All medications: prescribed, over-the-counter, herbal preparations; include nonpharmacologic agents
  • Potential drug-drug interactions
  • Adverse effects
  • Challenges with adherence to prescribed medications
I A E
Current General Medical Status and History
Immunizations
  • History of immunizations
  • Status of HIV- and age-related preventive immunizations

⇒ See NYSDOH AI Immunizations for Adults With HIV.

I A  
Age-related disease screening
  • Results of previous age-related disease screening tests
I A  
Cardiovascular
  • History of cardiac events, stroke, and treatment
  • History of hypertension
  • History of diabetes or insulin resistance
  • Risk factors for CVD
  • Family history of CVD
I A  
Respiratory
  • History of COPD and treatment
  • Current tobacco/vape use and smoking history
I A  
Cancer
  • History of prior malignancies and treatment
  • Previous age-appropriate screening and results
  • Family history of malignancies
I A  
Renal
  • History of renal disease and treatment
  • Consider ART history
  • Consider associated comorbidities
I    
Hepatic I    
Endocrine
  • Symptoms of thyroid dysfunction or hypogonadism
  • Sexual dysfunction
  • Weight loss or weight gain
  • Family history of metabolic syndrome and thyroid disease
  • History of osteoporosis and treatment, fractures, and previous screening
  • History of lipodystrophy and treatment
  • Use of hormonal therapy (including treatments obtained without prescription)

⇒ ART (current and previous) may contribute to metabolic syndrome, lipodystrophy, and insulin resistance.

I A  
Gastrointestinal
  • History of GI disease and treatment
  • GI-related adverse effects of medications and effect (if any) on adherence to prescribed medications
  • Family history of GI disease
I A  
Vision
  • Changes in vision, including blurry vision, double vision, flashes of light, loss of vision, use of glasses, and blindness or legal blindness
I A  
Hearing
  • Changes in hearing
  • Recent audiology testing or new hearing aid use
I A  
Neurologic

⇒ Symmetric distal polyneuropathy is common, particularly in patients exposed to earlier generations of ART.

I A  
Dermatologic
  • History of psoriasis and treatment
  • History of seborrheic dermatitis and treatment
  • History of atopic dermatitis and xerosis and treatment
  • History of skin cancer and treatment

⇒ Dermatitis can worsen with degree and duration of immunosuppression.

I A  

Surgery

I A  
Pain I   E
Sleep
  • History of chronic obstructive sleep apnea and treatment
  • History of sleep disturbances and treatment
I    
Nutrition
  • History of wasting
  • Dietary habits, appetite
  • Food insecurity

⇒ Note: If indicated, see USDA Food Security Surveys.

I   E
Frailty I A  
Travel
  • Recent travel; assess for potential exposure to infectious disease
  • Frequency and location of international travel (work or leisure)
  • Status of travel-related immunizations
  • Lifetime travel history, if indicated
I A  
Pets
  • Current and past pet ownership, including exotic animals
  • History of zoonotic diseases and treatment
I A  

Abbreviations: ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; GI, gastrointestinal; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; NYSDOH AI, New York State Department of Health AIDS Institute; OI, opportunistic infection; TB, tuberculosis; U=U, undetectable = untransmittable; UCSF, University of California, San Francisco; USDA, United States Department of Agriculture. 

Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV

Lead authors: Mary Dyer, MD, and Christine Kerr, MD, with the  Medical Care Criteria CommitteeFebruary 2021

Download Table 2 PDF

Guide to the tables: Although the tables are comprehensive in scope, this committee supports a flexible approach in using this guide to elements that should be included in a comprehensive initial history and physical. All aspects of the patient history and physical examination do not have to be covered in a single visit or by the primary care clinician per se. For some care providers and patients, the best approach may be to spend 2 or more visits completing the initial assessment and address some aspects of the history and physical during follow-up visits.

Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV
*Frequency Key: I = initial (baseline) visit; A = annual visit; N = as needed
Assessment To Include Frequency*
I A N
Gender and Sexual Identity
Gender identity
  • Current gender identity and sex assigned at birth
  • Pronouns
I A N
Current sexual identity
  • History of sexual identity
I A N
Gender transition
  • Gender transition goals; successes and challenges
  • History of, planned, or desired gender-affirming surgery
  • Current, past, or planned use of gender-affirming hormones
  • Source of gender-affirming hormones
  • Adverse effects of gender-affirming treatments
I    
Inventory of sexual organs
  • Presence or absence of penis, testes, prostate, breasts, vagina, cervix, uterus, ovaries, and determination of patient’s preferred terms for body parts
I A N
Current Psychosocial Status and History
Housing
  • Housing stability or connection to resources if housing is unstable
  • Relocation plans

⇒ Monitor for signs of instability.

I A N
Family and other significant relationships and responsibilities
  • Immediate and extended family members as defined by the patient
  • Significant relationships
  • Disclosure status
  • Financial and care-giving dependents, including children, spouse or life partner, aging parents, and extended or chosen family members
  • Community support, including functional needs and agency or family assistance
  • Transportation
  • Pets in home

⇒ Monitor for signs of instability.

I A  
Interpersonal and social support network
  • Members of the patient’s primary interpersonal and social support network
  • People to whom the patient has disclosed their HIV status
  • Discussion of experienced and perceived stigma

⇒ Monitor for signs of instability.

I A N
Employment
  • Current employment status or employment goals
  • Access to financial support if unemployed or under-employed
  • Employment-associated risks to health or well-being, including stigma and discrimination
I A  
Medical insurance
  • Access to private medical insurance, Medicaid, ADAP, or Medicare
  • Prescription coverage
  • Hospitalization coverage
  • Access to resources for coverage if uninsured
I A N
Incarceration
  • History of incarceration
  • Probation, parole, and other legal status
I    
End-of-life planning
  • Documented healthcare proxy
  • Documented preferences for end-of-life care and living will
  • Long-term care plans
I A  
Current Mental Health Status and History
Mental illness
  • History of mental illness and treatment
  • Adverse reactions to medications
  • History of psychiatric hospitalization
  • Suicide risk assessment and past history of suicide attempts
  • Family history

⇒ See Depression: Screening and Diagnosis; assess mental health using standardized tools, such as The Patient Health Questionnaire-2 (PQH-2), The Patient Health Questionnaire-9 (PQH-9), and the Columbia-Suicide Severity Rating Scale (C-SSRS).

I A  
Trauma
  • History of trauma, including domestic violence; physical, verbal, sexual, or emotional abuse; or witnessed trauma
  • History or current experience of elder abuse
  • Any effects on current function and coping strategies
I A N
Stress
  • Current major stressors
  • Stress management and coping skills
  • Current experience or history of HIV-associated or other stigmas
I A N
Current Substance Use and History
Alcohol
  • History of use, including use disorder diagnosis and treatment
  • Adverse reactions to medications
  • Screening for current use; if indicated, perform risk assessment using standardized tools. See the NYSDOH AI guideline Substance Use Screening and Risk Assessment in Adults.

⇒ If indicated, implement a harm reduction treatment plan.

I A N
Tobacco use and vaping
  • Current level of tobacco use and type
  • History of use and prior treatment
  • Adverse reactions to medications

⇒ Smoking prevalence is high in people with HIV [Pacek and Cioe 2015].

I A N
Use of nonprescription drugs and misuse of prescribed drugs
  • All types of drug use, including misused prescription medications
  • History of use, including use disorder diagnosis and treatment
  • Route of use
  • History of overdose
  • Screening for current use; if indicated, perform risk assessment using standardized tools. See the NYSDOH AI guideline Substance Use Screening and Risk Assessment in Adults.

⇒ If indicated, implement a harm reduction treatment plan.

I A N
Sexual and Reproductive Health and History
Sex partner(s) and activity
  • Current sex partner(s)
  • HIV, ART, and viral load status of partner(s), if known; PrEP and other measures to prevent STIs used by partner(s)
  • Frequency of and preferred sexual activities; challenges
  • History of sexual dysfunction
  • History of or current engagement in transactional sex

⇒ NYSDOH AI Resources: GOALS Framework for Sexual History Taking in Primary Care, U=U Guidance for Implementation in Clinical Settings

I A N
Sexually transmitted infections
  • History of and treatment for syphilis, gonorrhea, chlamydia, human papillomavirus, and other STIs
  • Source of prior treatment for any STI
  • Assessment of ongoing risk factors and implementation of harm or risk reduction plan if indicated; use of condoms or other barrier protection

⇒ Screening should include all potentially exposed sites. For evidence-based recommendations, see CDC > Sexually Transmitted Infections Treatment Guidelines, 2021 > Screening.

I A N
Reproductive history
  • Offspring
  • Previous failed attempts at reproduction
  • Previous treatment for reproductive issues and source
  • Adverse effects
  • Contraceptive history
  • Previous abortion(s)
I    
Reproductive goals
  • Family planning goals
  • Contraception use and options

⇒ Check for possible drug-drug interactions for individuals taking ART.

I   N
Abbreviations: ADAP, AIDS Drug Assistance Program; ART, antiretroviral therapy; NYSDOH AI, New York State Department of Health AIDS Institute; PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection; U=U, undetectable = untransmittable.
Reference

Pacek LR, Cioe PA. Tobacco use, use disorders, and smoking cessation interventions in persons living with HIV. Curr HIV/AIDS Rep 2015;12(4):413-420. [PMID: 26391516

Table 3: Recommended Laboratory Testing for Adults With HIV

Lead authors: Mary Dyer, MD, and Christine Kerr, MD, with the  Medical Care Criteria CommitteeFebruary 2021

Download Table 3 PDF

Guide to the tables: Although the tables are comprehensive in scope, this committee supports a flexible approach in using this guide to elements that should be included in a comprehensive initial history and physical. All aspects of the patient history and physical examination do not have to be covered in a single visit or by the primary care clinician per se. For some care providers and patients, the best approach may be to spend 2 or more visits completing the initial assessment and address some aspects of the history and physical during follow-up visits.

Table 3: Recommended Laboratory Testing for Adults With HIV
*Frequency Key: I = initial (baseline) visit; A = annual visit; N = as needed
Laboratory Test Comments Frequency*
I A N
HIV-1 RNA quantitative viral load
  • Regular monitoring is the most accurate and meaningful measure of effective ART.
  • Check every 3 to 6 months during years 1 and 2, and every 4 to 6 months thereafter.
  • Monitor every 1 to 3 months if adherence is unstable or patient has detectable viral load.

⇒ See the NYSDOH AI guideline Virologic and Immunologic Monitoring.

I A N
CD4 lymphocyte count
  • Check every 3 to 6 months if CD4 count <200 cells/mm3; not indicated if viral load is consistently undetectable (CD4 count >200 cells/mm3).
  • Monitor every 3 months if diagnosis is recent (<2 years), viral load suppression is inconsistent, or CD4 count is close to or below 200 cells/mm3.

⇒ See the NYSDOH AI guideline: Virologic and Immunologic Monitoring.

I A N
HIV-1 resistance testing (genotypic)
  • Perform at treatment initiation.
  • Perform if viral load is >500 copies/mL (archive genotype may be considered if VL below 500 copies/mL).
  • Consult with an expert in HIV care in the event of treatment failure.
I   N
G6PD
  • Screen for deficiency to avoid use of oxidant drugs, including dapsone, primaquine, sulfonamides.
  • Prevalence of G6PD deficiency is highest among people of African, Asian, or Mediterranean descent, but consider in all patients given diversity of backgrounds.
I    
Complete blood count
  • For patients not taking zidovudine, check at initiation of ART and repeat as clinically indicated.
  • For patients taking zidovudine, check at initiation, and 4 weeks after initiation; follow every 3 months for the first year, then every 6 months.

⇒ Consider with any change in medication.

I A  
Estimated glomerular filtration rate
  • For patients taking TDF, check at initiation, then repeat at 4 weeks, 3 months, 6 months, and 12 months for the first year, then every 6 months thereafter.
  • For patients not taking TDF, check at initiation, 6 months during the first year, then annually thereafter.
  • Check after initiation of medication with risk for renal disease (e.g., use of nonsteroidal anti-inflammatory agents, angiotensin-converting enzyme inhibitors).
  • Check if patient has history of diabetes or other renal diseases.
I A N

Hepatic panel:

  • Aspartate aminotransferase
  • Alanine aminotransferase
  • Alkaline phosphatase
  • Total bilirubin
  • Check 3 months after initiation of ART, after initiating medication with risk for liver disease (e.g., statins, azoles), or if there is a history of viral hepatitis, and then at 12 months.
  • Check every year if patient is stable and without above risks.
I A N
Random blood glucose (fasting or hemoglobin A1c if high)
  • Check every 6 to 12 months if a patient has risk factors for diabetes (family history, obesity, use of protease inhibitors or INSTIs).
  • If abnormal, repeat random glucose as a fasting glucose or A1C.

⇒ Results are used to diagnose diabetes. See Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers.

I A N
Tuberculosis screening
  • Obtain IGRA TB test (such as T-SPOT or QuantiFERON-TB) or tuberculin skin test (commonly known as PPD) at baseline for diagnosis of latent TB infection, unless the patient has previously tested positive for or has documented TB.
  • Repeat annually for patients at risk (e.g., unstable housing, incarceration, travel or immigration).

⇒ Consider preventive therapy for patients with ≥5 mm reaction to PPD. See: CDC: Treatment of LTB1 and TB for Persons with HIV and Clinical Info HIV.gov > Mycobacterium tuberculosis.

I A  

Hepatitis A

  • Anti-hepatitis A immunoglobulin
  • Repeat after vaccination to ensure immunity.

⇒ See the NYSDOH AI guideline Prevention and Management of HAV in Adults With HIV > Transmission and Prevention for testing and vaccination recommendations.

I   N

Hepatitis B

  • Surface antibody
  • Surface antigen
  • Core antibody
  • If HBsAg-positive or if HBcAb-positive but HBsAb-negative, perform HBV DNA viral load test.
  • Repeat HBsAb after vaccination to ensure immunity.

⇒ See the NYSDOH AI guideline HBV-HIV Coinfection > Baseline Evaluation and Screening for testing and vaccination recommendations.

I   N

Hepatitis C

  • HCV antibody
  • HCV RNA quantitative viral load
  • If patient was previously treated for HCV or is antibody-positive, perform HCV viral load test.
  • Check at entry to care; repeat as clinically indicated for patients with exposure risk.

⇒ See the NYSDOH AI guideline Treatment of Chronic HCV with Direct-Acting Antivirals > Diagnosis of HCV Infection.

I   N
Measles titer
  • Vaccinate if patient is not immune and has a CD4 count >200 cells/mm3.
I    
Varicella titer
  • For patients with no evidence of immunity and CD4 count >200cells/mm3, consider vaccination for chicken pox (Varivax; 2 doses, 3 months apart); engage patients in shared decision-making, taking into consideration the potential risks of a live vaccine.
  • Live vaccines are contraindicated for patients with CD4 counts <200cells/mm3.
  • Above 50 years of age, regardless of varicella titer status or CD4 cell count, consider vaccination for Herpes zoster with recombinant zoster virus (RZV; SHINGRIX) two doses 2 to 6 months apart.
I    
Urinalysis
  • Evaluate for proteinuria.
  • Check for symptoms of UTI or change in creatinine or other urinary symptoms (including glucosuria for patients on tenofovir).

⇒ See the NYSDOH AI guideline Antiretroviral Therapy > Laboratory Monitoring for Adverse Effects of ART.

I A N
Urine pregnancy test
  • Perform for all individuals of childbearing potential who are sexually active.
  • Repeat at patient request.
I   N
Lipid panel
  • Perform at least every 3 years if patient has increased risk for CVD.
  • Consider annual screening if patient is taking protease inhibitors.
  • For adults >75 years old, initiate discussion of possible benefits of age-appropriate preventive therapies in the context of comorbidities and life expectancy.

⇒ HIV is considered a risk-enhancing factor for CVD; clinicians may opt to perform more frequent lipid testing in patients with cardiovascular comorbidities.

I +/- N
Serum thyroid-stimulating hormone
  • Insufficient evidence exists for routine screening of nonpregnant adults.

⇒ Adults with HIV have higher incidence of thyroid dysfunction than those without HIV. Discuss annual screening. See USPSTF Thyroid Dysfunction: Screening.

I +/-  
Gonorrhea and chlamydia
  • Perform baseline testing at oral, anal, urethral, and cervical sites for MSM and TGW and others as indicated by individual exposure.
  • Repeat based on risk factors and sites of exposure.
  • Repeat every 3 months for MSM and TGW.

⇒ See Update to the CDC’s Treatment Guidelines for Gonococcal Infection, 2020.

I A N
Syphilis
  • Use same laboratory test consistently.
  • Repeat at least annually
  • Repeat every 3 months for patients with risk of exposure (e.g., MSM).

⇒ See the NYSDOH AI guideline Management of Syphilis in Patients with HIV.

I A N
Trichomonas
  • Perform screening test if the patient has a vagina and is sexually active.
I A N
HLA-B*5701
  • Must be performed before initiation of abacavir, otherwise not routine.
    N
Abbreviations: ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; MSM, men who have sex with men; CVD, cardiovascular disease; FDA, U.S. Food and Drug Administration; G6PD, glucose-6-phosphate dehydrogenase; HBcAb, hepatitis B core antibody; HBsAb, hepatitis B surface antibody; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; IGRA, interferon gamma release assay; INSTI, integrase strand transfer inhibitor; PPD, purified protein derivative; TB, tuberculosis; TDF, tenofovir disoproxil fumarate; TGW, transgender women; USPSTF, United States Preventive Services Taskforce; UTI, urinary tract infection.