Figure 1. Primary Care Management of HIV

Figure 2. HIV Testing Algorithm

Table 1. Initial Assessment—History—Present and Past

Past History

• HIV diagnosis: how, where, when and why was diagnosis was made
• Duration of infection: dates of prior negative tests and/or diagnosis and/or symptoms of acute retroviral syndrome
• HIV-related conditions: Infections, malignancies, or other conditions potentially related to HIV (e.g., thrush, oral hairy cell leukoplakia, herpes zoster, cervical or anal cancer or dysplasia, PCP or other opportunistic infections [OIs], Kaposi sarcoma, lymphoma, neuropathy, anemia, neutropenia, thrombocytopenia [115] and neurocognitive impairment)
• HIV Medications: Prior use of antiretroviral therapy including prevention for mother to child transmission or pre-/post-exposure prophylaxis, including specific drugs, duration of therapy, complications or side effects, drug resistance, virologic response and adherence
• Comorbidities: History of and risk factors for coronary heart disease, dyslipidemia, diabetes mellitus, kidney disease and osteoporosis
• Psychiatric history: treatment for or symptoms of depression, anxiety, suicidal ideation or PTSD: psychiatric hospitalizations
• Sexually transmitted diseases (STDs): gonorrhea, chlamydia, pelvic inflammatory disease, chancroid, syphilis, herpes simplex virus, viral hepatitis, human papilloma virus (HPV), and trichomoniasis, including treatment history and outcome
• Women: gynecologic and obstetric history, plans for future pregnancy, birth control practices, last Pap test, abnormal PAP test ever menstrual history, mammogram (if applicable)
• Pediatric: maternal obstetric and birth history, exposure to perinatal antiretroviral, exposure to infectious diseases, growth and development
• Health care maintenance:
  • Latent tuberculosis: history of TB or TB exposure and last screening test for latent TB, with treatment if applicable
  • Immunization history: childhood vaccination, dT or Tdap, hepatitis A and B, HPV, influenza meningococcal, pneumococcal, varicella/zoster, and travel vaccinations
  • Last eye exam, including dilated funduscopic exam
  • Last dental visit
• Past Medical History: Include any hospitalizations, surgeries, blood product receipt not mentioned above
• Family Medical History: diabetes, early heart disease, hypertension, cancer

Social History

• Race and ethnicity
• Gender and sexual identity
• Health-related behaviors: tobacco, alcohol, and drug use
• Patient birthplace, residence and travel history
• History of receipt of blood products, organ transplant, or semen donation
• Employment history
• Pets, diet and exercise;
• Establish mode(s) of infection:
  • Sexual contacts (men, women, both), types of activity, condom use
  • History of injection drug use, shared needles/syringes.
  • History of transfusion or receipt of blood products, especially 1975-1985. Artificial insemination by an unidentified donor
• Review specific sexual practices, including exposure sites
• Marital/relationship status, partner’s health and HIV status and his or her access to health care, including HIV testing, and disclosure of HIV status to partner(s)
• Social support and participation in support groups
• For minors review legal guardianship

Table 2. Initial Assessment—Review of Systems and Physical Examinations

Initial Assessment –
Review of Symptoms

A complete review of systems with special attention to the areas listed below:

• General: unexplained weight loss, night sweats, fever, changes in body habitus
• Skin: skin discoloration, rash, ulcers, or lesions
• Lymph nodes: localized or generalized enlargement of lymph nodes
• Eyes: vision change or loss
• Mouth: gum disease, ulcers, oral lesions or pain
• Cardiopulmonary: chest pain, shortness of breath, palpitations, wheezing, dyspnea, orthopnea
• GI: diarrhea, nausea, pain
• Endocrinology: symptoms of hyperglycemia, thyroid disease, hypogonadism
• Neurologic and psychiatric: persistent and severe headaches, memory loss, loss of concentration, depression, apathy, anxiety, mania, mood swings, lower extremity paresthesias, pain, or numbness, paralysis or weakness, cognitive difficulties, dizziness, seizures, sleep disorders
• Genitourinary: dysuria, urethral or vaginal discharge or lesions, hematuria
• Orthopedic: hip pain, joint pain, fractures, diagnosis of or risk factors for osteopenia/osteoporosis
• Developmental milestones: for infants and young children asses for motor or speech delays

Initial Assessment –
Physical Examination

A complete physical examination should be performed on all patients. Additionally, special attention should be paid to the following areas:

• Vital signs: including height and weight
• General including body habitus, evidence of obesity, wasting, lipodystrophy, assessment of frailty and ambulatory ability
• Skin: seborrheic dermatitis, ecchymoses, purpura, petechiae, Kaposi’s sarcoma, herpes simplex or zoster, psoriasis, molluscum contagiosum, onychomycosis, folliculitis, condylomata, cutaneous fungal infections
• Lymph nodes: generalized or localized lymphadenopathy
• Eye: retinal exudates or cotton wool spots, hemorrhages, pallor, icterus
• Oropharynx: oral hairy leukoplakia, candidiasis (thrush, palatal erythema, angular cheilosis), aphthous ulcers, gingivitis, periodontal disease, Kaposi’s sarcoma, tonsillar or parotid gland enlargement
• Cardiovascular: heart exam, peripheral pulses, presence/absence of edema
• Chest: Lung examination
• Breast: nodules, nipple discharge
• Abdomen: hepatomegaly, splenomegaly, masses, tenderness
• Genitourinary: ulcers, warts, chancres, rashes, abnormal gynecologic exam, discharge
• Anorectal: ulcers, warts, fissures, internal or external hemorrhoids, masses, Kaposi’s sarcoma
• Neuropsychiatric: depression, mania, anxiety, signs of personality disorder, difficulties in concentration, attention, and memory, signs of dementia, speech problems, gait abnormalities, focal deficits (motor or sensory), lower extremity vibratory sensation (distal sensory neuropathy, abnormal reflexes.)

• A comprehensive present and past medical history, physical examination, medication/social/family history, and review of systems, including HIV-related information, should be obtained for all patients upon initiation of care (SR-M).

HIV Disease Tests: Serological Assays for HIV

• Patients who have no documentation of their HIV serostatus or who were tested anonymously should have an HIV serologic test performed upon initiation of care (SR-L).

CD4 Cell Counts and Percentages

• A CD4 cell count with percentage should be obtained upon initiation of care (SR-H).
• Measurement of the CD8 cell count and the ratio of CD4 cells to CD8 cells is unnecessary as the results are not used in clinical decision making (SR-H).

Plasma HIV RNA Levels

• A quantitative HIV RNA (viral load) level should be obtained upon initiation of care (SR-H).

HIV Resistance Testing

• Because drug-resistant virus can be transmitted from one person to another, all patients should be assessed for transmitted drug resistance with an HIV genotype test upon initiation of care (SR-H). If therapy is deferred, repeat testing at the time of antiretroviral therapy (ART) initiation should be considered because of the potential for superinfection (WR-L).
• Resistance testing is also indicated for patients who are experiencing virologic failure, to guide modification of ART (SR-H).
• In persons failing to respond to integrase strand transfer inhibitor (INSTI)-based regimens, genotypic testing for INSTI resistance should be ordered (SR-H).

Coreceptor Tropism Assay

• Tropism testing should be performed if the use of a CCR5 antagonist is being considered (SR-H).

Laboratory Tests

Complete Blood Cell Count and Chemistry Panel

• A complete blood cell count with differential white blood cell count and chemistry panel should be obtained upon initiation of care (SR-H).

Glucose-6-Phosphate Dehydrogenase

• Screening for glucose-6-phosphate dehydrogenase (G6PD) deficiency is recommended upon entry into care or before starting therapy with an oxidant drug in patients with a predisposing racial or ethnic background (SR-M).

Fasting Lipid Profile

• Because many antiretroviral drugs, HIV infection itself, and host factors are associated with increased cholesterol and triglyceride levels, a fasting lipid profile should be obtained upon initiation of care (SR-H).

HLA B*5701 Screening

• HLA-B*5701 testing should be performed before initiating abacavir therapy (SR-H).
• Patients who are positive for the HLA B*5701 haplotype are at high risk for hypersensitivity reaction and should NOT be treated with abacavir (SR-H).

Urinalysis and Calculated Creatinine Clearance

• A baseline urinalysis should be performed and baseline calculated creatinine clearance or estimated glomerular filtration rate should be obtained, especially in black HIV-infected patients and those with advanced disease or comorbid conditions, because of an increased risk of nephropathy (SR-H).
• Urinalysis and calculated creatinine clearance assay should also be performed prior to initiating the use of drugs that have the potential for nephrotoxicity such as tenofovir or indinavir (SR-M).

Coinfection and Comorbidity Laboratory Tests

Tuberculosis Screening

• Upon initiation of care, HIV-infected patients without a history of tuberculosis or a prior positive tuberculosis screening test result should be tested for Mycobacterium tuberculosis infection by either a tuberculin skin test (TST) or by an interferon-γ release assay (IGRA) (SR-H). Those with positive test results should be treated for latent M tuberculosis infection after acute tuberculosis has been excluded (SR-H).
• Repeat testing is recommended in patients with advanced HIV disease who initially had negative TST or IGRA results but subsequently experienced an increase in the CD4 cell count to >200/μL on ART and who may thus have developed sufficient immunocompetence to mount a positive reaction (SR-H).
• HIV-infected patients who are close contacts of persons with infectious tuberculosis should be treated for latent M tuberculosis infection regardless of their TST or IGRA results, age, or prior courses of tuberculosis treatment. Active tuberculosis should be excluded first (SR-H).

Serologic Testing for Toxoplasma gondii

• All HIV-infected patients should be tested for prior exposure to T gondii by measuring anti-Toxoplasma immunoglobulin G (IgG) upon initiation of care (SR-M).
• Toxoplasma-seronegative adults, representing 70%-90% of the US population, should be counseled on how to avoid new infection (WR-M).

Viral Hepatitis Screening and Vaccination Recommendations

• HIV-infected patients should be screened for evidence of hepatitis B virus (HBV) infection upon initiation of care by detection of hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and antibody to hepatitis B total core antigen (anti-HBc; also abbreviated as HBcAb) (SR-H), and those who are susceptible to infection should be vaccinated against HBV (SR-H). HBsAb testing should be repeated 1-2 months after the third vaccine is given, or at the next scheduled visit after the third vaccine is given, to assess for immunogenicity. A second series of vaccination is recommended for those whose HBsAb levels are negative or <10 IU/mL after the primary vaccine series (SR-H).
• Vaccination should be recommended for nonimmune sexual partners of patients who are positive for HBsAg (SR-H).
• Patients who are negative for HBsAg and HBsAb but positive for anti-HBc should be screened for chronic HBV infection by determination of HBV DNA. Those without evidence of chronic infection should consider vaccination (SR-L).
• HIV-infected patients should be screened for hepatitis C virus (HCV) infection upon initiation of care by a test for HCV antibody and annually thereafter for those at risk (SR-H).
• HCV RNA testing should be ordered on all those with a positive HCV antibody test result to assess for active HCV disease (SR-H).
• Infants born to HBV- and/or HCV-infected women should be tested for HBV and HCV transmission, respectively (SR-H).
• Hepatitis A vaccination is recommended for all susceptible men who have sex with men (MSM), as well as other susceptible individuals with indications for hepatitis A vaccine (eg, injection drug users, persons with chronic liver disease, travelers to countries with high endemicity, or patients who are infected with hepatitis B and/or C) (SR-H). Hepatitis A total or IgG antibody testing should be repeated 1-2 months after the second vaccine is given, or at the next scheduled visit after the second vaccine is given, to assess for immunogenicity. A repeat vaccine series is recommended in those who remain seronegative (SR-H).
• Hepatitis A vaccine may be considered for all other nonimmune patients (negative anti-HAV [hepatitis A virus] total or IgG antibody) (WR-L).

Screening and Vaccination Recommendations for Herpes Viruses

• Patients at lower risk of cytomegalovirus (CMV) infection (eg, populations other than MSM or injection drug users, both of which may be assumed to be seropositive) should be tested for latent CMV infection with an anti-CMV IgG upon initiation of care (SR-M).
• Patients who are susceptible to varicella zoster virus (VZV) (those who have not been vaccinated, have no history of varicella or herpes zoster infection, or are seronegative for VZV) should receive postexposure prophylaxis with varicella zoster immune globulin (VariZIG®) as soon as possible (but within 10 days) after exposure to a person with varicella or shingles (SR-M).
• Varicella primary vaccination may be considered in HIV-infected,
  VZV-seronegative persons >8 years of age with CD4 cell counts
  >200/μL (MR-L) and in HIV-infected children ages 1-8 years with CD4 cell percentages >15% (SR-M).

Screening for Syphilis

• All patients should be screened for syphilis upon initiation of care and periodically thereafter, depending on risk (SR-H).
• A lumbar puncture should always be performed for patients with a reactive syphilis serology who have neurologic or ocular symptoms or signs, irrespective of past syphilis treatment history (SR-H).
• A lumbar puncture should be performed in patients who experience serologic treatment failure (ie, whose nontreponemal titers fail to decline 4-fold after stage-appropriate therapy, or whose titers increase 4-fold if reinfection is ruled out) (WR-L).

Screening for Other Sexually Transmitted Diseases

• All women should be screened for trichomoniasis, and all women ≤25 years of age should be screened for Chlamydia trachomatis infection (SR-H).
• Men and women should be screened for gonorrhea and chlamydia infection at initial presentation and then annually if at risk for infection (SR-H).
• Retesting in 3 months is indicated in men and women found to be positive for gonorrheal and chlamydial infections and women found to be positive for trichomoniasis on initial screening, because of high reinfection rates (SR-M).
• Patients should be screened for all of these conditions periodically thereafter, depending on the population, reported behaviors, the presence of other sexually transmitted diseases (STDs) in the patient or his/her partner(s), and the prevalence of STDs in the community (SR-L).

Cervical Cancer Screening and Prevention

• HIV-infected women should have a cervical Pap smear performed upon initiation of care, and this test should be repeated at 6 months and annually thereafter if results are normal (SR-M).
• Women with atypical squamous cells (both ASC-US [atypical squamous cells of unknown significance] and ASCH [ASC, cannot rule out high-grade squamous intraepithelial lesion]), atypical glandular cells, low-grade or high-grade squamous intraepithelial lesion, or squamous carcinoma noted by Pap testing should undergo colposcopy and directed biopsy, with further treatment as indicated by results of the evaluation (SR-H).

Screening for Anal Human Papillomavirus

• HIV-infected men and women with human papillomavirus (HPV) infection are at increased risk for anal dysplasia and cancer. MSM, women with a history of receptive anal intercourse or abnormal cervical Pap test results, and all HIV-infected persons with genital warts should have anal Pap tests (WR-M).
• HPV vaccination is recommended for all females ages 9-26 years and all males ages 9-21 years. Males 22-26 years of age should also be vaccinated if not vaccinated at younger ages (SR-H).

Serum Testosterone Level

• Morning serum testosterone level testing is recommended in adult men with decreased libido, erectile dysfunction, reduced bone mass or low trauma fractures, hot flashes, or sweats, and should be considered in the setting of less-specific symptoms such as fatigue and depression (SR-M).
• Obtaining testosterone levels in women in nonresearch settings is NOT recommended (SR-L).

Other Laboratory Tests

• Routine testing for cryptococcal infection with serum cryptococcal antigen or for disseminated Mycobacterium avium complex infection by culture of blood for acid-fast bacilli is NOT recommended, but may be considered in selected patients with CD4 cell counts <50/μL (SR-M).

Chest Radiology

• A baseline chest radiograph should be obtained in all HIV-infected patients with a positive tuberculosis screening test result to rule out active tuberculosis. It may also be useful in other patients who are likely to have preexisting lung abnormalities (SR-M).