Initial Evaluation

History Review of Systems and Physical Examination

Laboratory Studies Spectrum of HIV Disease

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History

In addition to reviewing past medical, family medical, and social histories, medications, and allergies, the following issues should be addressed:

• HIV risk behaviors
  
• knowledge of HIV infection
  
• emotional response to diagnosis
  
• family and social situation
  
• employment and insurance status
  
• exposure to tuberculosis, syphilis, other sexually transmitted diseases, and viral hepatitis (A, B, and C)
  

If another provider previously followed the patient, prior opportunistic diseases, CD4 cell count and HIV viral load results, and antiretroviral therapy chronology, including reasons for discontinuation of specific agents, are also important.

Review of Systems and Physical Examination

Attention should focus on the following organ system symptoms and signs and on screening for HIV-related conditions:

• constitutional symptoms: fever, chills, night sweats, weight loss
  
• integument: seborrhea, psoriasis, onychomycosis, herpes simplex virus, varicella zoster virus, Kaposi's sarcoma, generalized adenopathy
  
• HEENT: altered vision, dysphagia, cytomegalovirus retinitis, thrush, oral hairy leukoplakia, periodontal disease
  
• pulmonary: cough, dyspnea, pneumocystis pneumonia
  
• gastrointestinal: odynophagia, diarrhea, organomegaly
  
• genitourinary: vaginitis, pelvic inflammatory disease, human papilloma virus, cervical dysplasia, anal carcinoma
  
• neurological: headache, problems with memory, change in behavior or personality, focal findings
  

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Laboratory Studies

Baseline laboratory evaluation is performed to assess for organ system dysfunction, to stage and monitor HIV disease, and to screen for other important disorders. Recommended studies include the following:

• complete blood and differential counts
  
• BUN/creatinine, liver function tests, glucose, lipid profile
  
• CD4 cell count (see below)
  
• HIV viral load (see below)
  
• RPR or VDRL
  
• anti-HAV
  
• HBcAb (HBsAb if prior immunization)
  
• anti-HCV
  
• toxoplasmosis serology
  
• PPD testing
  
• Pap smear in women
  

The following tests are important for the staging and monitoring of HIV disease:

CD4 Cell Count

• main surrogate marker for HIV disease progression
  
• normal range is 350 to 1100/mm3; there is average decline of 75-100/mm3 per year without treatment but variability between patients and in a given patient over time
  
• intercurrent illnesses may transiently affect value
  
• use caution in comparing values from different laboratories
  
• clinical uses are to determine need for and to monitor antiretroviral therapy, to determine risk for opportunistic diseases and need for antimicrobial prophylaxis, and to assess prognosis
  

HIV Viral Load

• measurement of viral RNA in plasma by polymerase chain reaction (PCR) or branched DNA (bDNA) techniques
  
• because PCR results may be up to twice as high as bDNA results, the same type of assay should be used over time in individual patients
  
• range of ultrasensitive PCR assay is < 50 to > 100,000 copies/ml
  
• high level correlates with CD4 cell count decline and clinical disease progression
  
• normal variability of 0.3 log (three- to five-fold)
  
• intercurrent illnesses and immunizations may transiently affect value
  
• clinical uses are to determine need for and to monitor antiretroviral therapy and to assess prognosis
  

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Spectrum of HIV Disease

Patients are at risk for the following medical conditions at listed CD4 cell count thresholds:

CD4 Cell Count > 500/mm³

• most patients asymptomatic
  
• bacterial infections, tuberculosis, shingles, other dermatologic conditions
  

CD4 Cell Count 500-200/mm³

• many patients asymptomatic
  
• generalized adenopathy, thrush, Kaposi's sarcoma
  

CD4 Cell Count < 200/mm³

• pneumocystis pneumonia, toxoplasmosis, cryptococcosis

CD4 Cell Count < 50/mm³

• cytomegalovirus and Mycobacterium avium complex infections
  
• increased risk of lymphoma
  
• mortality highest
  

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Comments about these guidelines are welcome and can be sent to the author at hlibman@caregroup.harvard.edu