A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 3: Core Elements of HIV Primary Care Table 3-1. Initial History and Physical Examination: Key Areas for Patients with HIV/AIDS History 3 Emotional reaction to HIV diagnosis HIV-specific information Risk assessment Past medical history Social history Vital signs, weight, height Skin Availability of friends and family for support First known positive HIV test Documentation of positive HIV test Possible timing and risk factors for HIV infection Opportunistic illnesses Prior CD4 counts, viral load measurements, and resistance tests Prior antiretroviral therapy and side effects Understanding of HIV disease Transmission, natural history of immune-response destruction and opportunistic infections, significance of CD4 counts and viral load, and antiretroviral therapy Risk category Sexual behavior history (see Table 2-2) Current sexual activity History of syphilis and other STDs Substance abuse history Intravenous and other substance abuse Rehabilitation and interest in rehabilitation Use of alternative medicine Mental health history Reproductive history, including pregnancies since becoming HIV positive, and plans for pregnancy Tuberculosis history History of positive PPD test, TB disease, or treatment of latent TB infection Concurrent medical conditions (diabetes, coronary artery disease, hypertension, etc.) Hospitalizations Housing Food sources, 3-day diet history Income, employment, and insurance Emergency contacts Legal issues Living will and durable power of attorney for medical decisions Permanency planning for dependent children Physical Examination Dermatitis, folliculitis, fungal infections, molluscum, and Kaposis sarcoma HEENT Retinal exam (with CD4 < 200/mm 3 ) Oropharynx: oral hairy leukoplakia, candidiasis, dentition Lymph nodes Abdomen Neurologic status Genital and rectal findings Cervical, axillary, inguinal Liver and spleen Special focus on mental status and sensation Discharges, ulcers, and warts 14 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 3: Core Elements of HIV Primary Care What are important aspects of the initial history in asymptomatic patients? The encounters should be tailored to the idiosyncrasies of the individual patient’s needs supplemented with the collection of some routine information about their HIV and general health status. The patient’s most pressing concern may require confirming the diagnosis, addressing denial, dealing with “HIV hysteria,” evaluating conditions unrelated to HIV, or evaluating for antiretroviral therapy (ART). For patients with prior medical treatment for HIV infection, the previous records are often critical for efficiency in time and cost. When possible, these should be brought by the patient or sent in advance of the visit. The type of information that is particularly useful is the record of CD4 cell counts and viral loads, HIV-related complications, current and prior medications, including information about tolerance, toxicity, and adherence (see Table 3-1). • Therapy Potent antiretroviral therapy (ART, also called highly active antiretroviral therapy, or HAART) has revolutionized the course of this disease. Although a miraculous development, HAART is also terribly demanding for the patient in terms of adherence, and some patients have big problems with side effects that are either short-term (eg, nausea, rash, asthenia) or long-term (eg, fat redistribution, hyperlipidemia, peripheral neuropathy). The benefits clearly outweigh the risks, and HIV is no longer an inevitably progressive disease, but is a chronic condition such as hypertension or diabetes that requires continual observation and care. • Cure No cure yet and unlikely to be with any of the current medications. • Prevention See discussion below. For more information, see Chapter 2: Approach to the Patient (section on Patient Education, especially Table 2-1, Information Resources for Patients). 3 What information do patients need to know about HIV? HIV is a chronic infection, which will be lifelong, and its outcome will depend to a large extent on the patient’s understanding of the disease process and management. Parallels with type 1 diabetes are clear. With this in mind, it is very important that the patient have access to information to advance his or her understanding of the disease. Essential knowledge includes: • Transmission Sex, injection drug use, and perinatal transmission are the “big 3” and have accounted for virtually all cases in the United States since blood began being screened in 1985. • Natural history Explain the 5 stages: 1) acute HIV, 2) seroconversion, 3) long period with no symptoms and decreasing CD4 cell count, 4) complications when the CD4 cell count is 500/ mm 3 ; a count of
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