The clinical approach to the HIV-infected patient should be guided by several important principles. First, it is important to establish the degree of immunosuppression in every patient through the history and physical examination and the measurement of absolute CD4+ lymphocyte count. Second, an individual’s risk of disease progression can be assessed through the measurement of plasma HIV RNA levels. Third, past histories of sexually transmitted diseases (STDs), positive purified protein derivative (PPD) testing or exposure to tuberculosis, and places of residence may be very useful in predicting complications of HIV infection. Finally, the sharing of pertinent medical information with patients may improve the quality of personal observations that they report to the physician in subsequent visits. Such educational efforts may result in greater adherence to medications and may also improve the physician’s ability to establish early diagnoses, provide effective outpatient treatment, and communicate regarding treatment options and risk reduction. Information regarding the stage of HIV disease, and thus the degree of immunosuppression, provides important insight into predicting clinical complications and guiding therapeutic decisions. Such a clinical approach will allow the physician to optimize the chronic management and counseling of HIV-infected persons.
The Initial Evaluation (
The initial evaluation of an HIV-infected person should begin with a careful history of past evaluations for HIV infection. Previous history of risk behaviors, mononucleosis-like symptoms that could represent acute HIV infection, and previous HIV testing may all offer insight into a patient’s duration of HIV infection. Previous plasma HIV RNA levels, CD4+ lymphocyte counts, history of acquired immunodeficiency syndrome (AIDS) indicator conditions, and other clinical manifestations are important historical factors.
The physician must also elicit a medical history, especially a history of STDs (syphilis, herpes simplex, hepatitis B and C, genital or perianal warts, and Cervical dysplasia are important examples), past PPD testing or exposure to tuberculosis, substance abuse, and medication allergies. On physical examination, particular attention should be focused on the skin (severe seborrhea, molluscum contagiosum, chronic herpetic ulcerations, and Kaposi’s sarcoma all suggest progressive HIV infection), lymph nodes (generalized lymphadenopathy usually correlates with earlier HIV infection and involution may signal progression of disease), oropharynx (candidiasis, oral hairy leukoplakia, and Kaposi’s sarcoma indicate progression), genitalia (severe warts, recurrent vaginal candidiasis, frequently recurrent or severe herpetic ulcerations, Cervical dysplasia, and Kaposi’s sarcoma suggest progression), and central nervous system (neurocognitive and memory deficits suggest progression to AIDS dementia).
The initial laboratory examination should include a complete blood cell count with differential; routine chemistries including liver enzymes and serum creatinine, plasma HIV RNA level, absolute CD4+ lymphocyte count, and CD4+ lymphocyte percentage; and syphilis and Toxoplasma serologies. Patients should also undergo 5-TU PPD testing; a positive response in an HIV-infected patient is defined as induration of 5 mm or more. All HIV-infected patients should receive the pneumococcal pneumonia vaccine due to their increased risk of pneumococcal infections. The hepatitis B vaccine may be given to previously uninfected patients, and the influenza vaccine may be given yearly.
Once the initial evaluation is complete, the physician should be able to establish a Centers for Disease Control and Prevention (CDC) classification and assess the patient’s risk of disease progression. In addition, potential co-infections with Treponema pallidum or Mycobacterium tuberculosis should be recognized and treated for personal and public health benefits. Finally, counseling may result in the reduction of risk behaviors through education and the identification and treatment of substance abuse.
Revision date: July 5, 2011
Last revised: by Andrew G. Epstein, M.D.