Print

Baseline Evaluation

(Last updated:5/1/2014; last reviewed:5/1/2014)

Every HIV-infected patient entering into care should have a complete medical history, physical examination, and laboratory evaluation and should be counseled regarding the implications of HIV infection. The goals of the initial evaluation are to confirm the diagnosis of HIV infection, obtain appropriate baseline historical and laboratory data, ensure patient understanding about HIV infection and its transmission, and to initiate care as recommended in HIV primary care guidelines1 and guidelines for prevention and treatment of HIV-associated opportunistic infections.2 The initial evaluation also should include introductory discussion on the benefits of antiretroviral therapy (ART) for the patient’s health and to prevent HIV transmission. Baseline information then can be used to define management goals and plans. In the case of previously treated patients who present for an initial evaluation with a new health care provider, it is critical to obtain a complete antiretroviral (ARV) history (including drug resistance testing results, if available), preferably through the review of past medical records. Newly diagnosed patients should also be asked about any prior use of ARV agents for prevention of HIV infection.

The following laboratory tests performed during initial patient visits can be used to stage HIV disease and to assist in the selection of ARV drug regimens:

  • HIV antibody testing (if prior documentation is not available or if HIV RNA is below the assay’s limit of detection) (AI);
  • CD4 T-cell count (CD4 count) (AI);
  • Plasma HIV RNA (viral load) (AI);
  • Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen (BUN), and creatinine, urinalysis, and serologies for hepatitis A, B, and C viruses (AIII);
  • Fasting blood glucose and serum lipids (AIII); and
  • Genotypic resistance testing at entry into care, regardless of whether ART will be initiated immediately (AII). For patients who have HIV RNA levels <500 to 1,000 copies/mL, viral amplification for resistance testing may not always be successful (BII).

In addition, other tests (including screening tests for sexually transmitted infections and tests for determining the risk of opportunistic infections and need for prophylaxis) should be performed as recommended in HIV primary care and opportunistic infections guidelines.1,2

Patients living with HIV infection often must cope with many social, psychiatric, and medical issues that are best addressed through a patient-centered, multi-disciplinary approach to the disease. The baseline evaluation should include an evaluation of the patient’s readiness for ART, including an assessment of high-risk behaviors, substance abuse, social support, mental illness, comorbidities, economic factors (e.g., unstable housing), medical insurance status and adequacy of coverage, and other factors that are known to impair adherence to ART and increase the risk of HIV transmission. Once evaluated, these factors should be managed accordingly. The baseline evaluation should also include a discussion of risk reduction and disclosure to sexual and/or needle sharing partners, especially with untreated patients who are still at high risk of HIV transmission.



Education about HIV risk behaviors and effective strategies to prevent HIV transmission should be provided at each patient visit (see Preventing Secondary Transmission of HIV).

#1503 - Gamma interferon release assays to diagnose latent TB

August 2015 - Feedback

Interferon gamma release assays (IGRAs), such as the QuantiFERON-TB Gold assay, detect circulating T cells reactive with antigens of Mycobacterium tuberculosis. The tuberculin skin test (TST) also detects M. tuberculosis-reactive T cells but T cells reactive with antigens of BCG and non-tuberculous mycobacteria may also be detected, resulting in a higher rate of false positive tests for M. tuberculosis infection. Although IGRA results do not always concur with TST results, there are several practical advantages to using IGRAs rather than TSTs.  In people with HIV infection, IGRAs are of value in the diagnosis of latent tuberculosis infection [1] but should not be used to exclude active tuberculosis (TB) because impairment of T cell responses may result in a false negative result. Accumulating data indicate that IGRA results predict the long-term risk of TB in HIV patients. [2,3]
 
IGRAs are recommended for patients who have been exposed to people with TB or are from a country with a high prevalence of TB.
 
References
[1] Cattamanchi A, et al.  JAIDS. 2011;56:230-238.
[2] Diel R, et al. Am J Respir Crit Care Med. 2008;177:1164-70.
[3] Aichelburg MC, et al. Clin Infect Dis. 2009;48:954-62.

 

#1504 - Baseline chest x-ray
August 2015 - Feedback
 
A baseline chest x-ray is recommended for all newly diagnosed HIV patients who have a CD4+ T cell count of <200/µL, report symptoms suggestive of respiratory tract disease, or have been exposed to people who have TB or are from a country with a high prevalence of TB.

#1505 - Hepatitis testing recommendations in homosexual men
August 2015 - Feedback

In Australia guidelines for testing for sexually transmitted infections in gay men have been developed by the STIs in Gay Men Action Group (STIGMA). Annual HCV antibody screening is recommended for asymptomatic MSM with HIV. In addition, antibody screening when there is clinical suspicion of HCV infection (e.g. elevated serum alanine aminotransferase, ALT, levels) is indicated. Seroconversion after acute hepatitis C infection usually occurs 4 to 12 weeks after infection, however seroconversion in HIV positive patients can be delayed and 5% may not have anti-HCV after 12 months of active HCV replication. [1] Mathematical modelling of effectiveness and cost-effectiveness supports annual HCV antibody screening in HIV positive MSM. [2] HCV PCR should be considered in patients who have otherwise unexplained abnormalities in liver function tests even if they are HCV antibody negative.

References
[1] Thomson EC, et al. Aids. 2009;23(1):89–93.
[2] Linas BP, et al. CID. 2012 Jul;55(2):279-90.



References

  1. Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis. 2014;58(1):e1-34. Available at http://www.ncbi.nlm.nih.gov/pubmed/24235263
  2. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed January 6, 2014.

ASHM - Supporting the HIV, Viral Hepatitis and Sexual Health Workforce