| Staging Staging and activity of the disease needs to be evaluated. Staging
includes the determination of underlying diseases that may impact upon treatment
approaches. Tuberculosis infection status and immunization status must be assessed. Blood
testing ideally should be done 3-4 weeks before the first formal visit to make this first
meeting more productive but can be done at the initial assessment, acknowledging the fact
that counseling on prognosis and frequency of follow-up visits cannot be adequately
determined until these results, particularly that of the CD4 count and viral load, are
received. |
AIDS-Indicator
Conditions in Adults and Adolescent with AIDS, Reported in 1996, United States
| Most
Frequently Reported Conditions* |
|
| Pneumocystis
jiroveci Pneumonia |
|
| HIV wasting
syndrome |
|
| Esophageal
candidiasis |
|
| Kaposi's
sarcoma |
|
| M.
tuberculosis infection |
|
| Severe herpes
simplex |
|
| Recurrent
pneumonia |
|
* Many persons
with AIDS have more than one condition
Source: CDC |
|
Before you begin antiretroviral
therapy:
- Verify that the patient is HIV-positive
- Repeat HIV testing for anonymous or home testing
- Order confirmatory testing from a licensed laboratory
(all tests should be performed at the same laboratory for consistency in results)
|
|
Laboratory tests to be drawn should include a repeat HIV antibody if access to the
actual laboratory report that referred the patient to you is unavailable. Other bloodwork
includes the CD4 lymphocyte count, which can provide an immediate assessment of a
patient's immune status, how they may respond to medications and how closely they may need
to be followed up. |
Patients with lower CD4 counts may have a less satisfactory response and more side effects
to medications, although good responses are possible at all stages of the disease. Disease
progression varies markedly from person to person, and unless the patient can recount the
exact timing of a unique risk exposure, point of infection is impossible to determine from
the count alone. It can be stressed to patients that trying to determine when they might
have become infected has little benefit. Rather, the physician and patient need to deal
with the current status of the patient's immune system and what steps can be taken.
|
Laboratory
tests you should order:
- Viral load (to measure the amount of virus present)
-
- CD4+ cell counts (best marker for the status of the
immune system)
|
Other
laboratory tests you should order:
- RPR (for syphilis)
- Toxoplasma antibody
- Cytomegalovirus (CMV) antibody
- Serology for hepatitis B and hepatitis C
- Baseline PPD (for tuberculosis)
- Baseline CBC
- Chemistry panel, including glucose, cholesterol and
triglycerides
|
An HIV-1 RNA viral quantitation assay by PCR, otherwise known as the viral load or viral
burden, should be checked with the CD4 cell count. Viral load is used to measure virus
activity and can dictate when antiretrovirals should be initiated or changed, even with
relatively high CD4 lymphocyte counts. A complete blood count, biochemistry panel
(including liver function profile, glucose, cholesterol and lipid panels), RPR, hepatitis
B and C profiles and a TORCH profile, which includes serologies for toxoplasma,
cytomegalovirus (CMV) and herpes simplex virus, should also be obtained. Collecting a
TORCH rather than ordering toxoplasma and CMV titers individually is usually more
cost-effective. These serve as baseline markers for potential opportunistic infections if
CD4 counts drop low enough. Checking sedimentation rates, beta-2 microglobulin and serum
cryptococcal antigens add little information to initial screenings.
|
Other assessments that should be
done:
- Nutritional
- Immunzation status (eg, pneumovax, hepatitis B, etc.)
- Assessment of other medical problems, such as
hypertension, diabetes mellitus, etc.
- Screening pap smear, with regular follow-up
- Screening retinal exam, with regular follow-up as
appropriate
|
|
A thorough history should be obtained during the initial medical evaluation. Known drug
allergies and patient's weight should be recorded and a complete physical exam performed.
A chest x-ray, PA and lateral, should be considered, particularly if the patient is
thought to be at risk for tuberculosis infection. Pneumococcal vaccine and, if applicable,
influenza and hepatitis B vaccines should be given as well. |
Influenza vaccine is especially pertinent for patients in the health care field or who
otherwise are exposed to large numbers of people at risk of getting influenza. Purified
protein derivative (PPD) should be applied for those with a negative history of a reactive
skin test result. |
The best medical interventions available will be undermined by a defective support
structure. Assessment of financial and social status, including family/emotional support,
housing, and active substance abuse, is critical if an impact is to be made clinically.
These issues inevitably take precedence during the initial stages of medical intervention.
Factors such as nutrition, smoking, alcohol and physical activity also need to be
discussed. Lastly, rapport needs to be established. Many of these patients have had
limited or suboptimal interactions with the health care system, either because of lack of
insurance or even lifestyle situations. If compassion and interest are shown in the
treatment of their condition, these patients stand a greater chance of returning for
follow-up and being compliant, even when much of the rest of their lives may in disorder. At
the initial follow-up visit, the physician should confirm that the patient understood what
was said at the previous meeting. So much information is provided at first, even the most
medically sophisticated patient may have trouble absorbing all the details. This follow-up
provides an important opportunity to review and clarify issues. Blood test results should
be reviewed at this visit, and the prospect of initiating medical therapy, if indicated,
should be discussed, with the understanding that it is as much the patient's decision as
the physician's. If the patient is not ready to commit to frequently burdensome medical
regimens, treatment initiation may have to be deferred rather than risk the prospect of
resistance developing because of poor compliance. Follow-up on insurance and entitlement
status should also be reviewed at this visit, with referral for psychiatric counseling or
to an AIDS support group discussed, if appropriate. |
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