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A
Guide To Primary Care For
People With HIV/AIDS, 2004 edition |
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Chapter
3
Core Elements Of HIV Primary Care
John McNeil,
MD
John V. L. Sheffield, MD
John G. Bartlett, MD
Initial
Evaluation
TOP
What are
the goals of the initial evaluation?
The goals will
depend to a large extent on why the patient is being seen by the
primary care provider, which may be because of symptoms, the need
for evaluation after a positive HIV test, referral, for a consultation,
etc. The initial evaluation should be tailored to the patient's
specific need, but the following are the usual goals of the initial
evaluation:
- Evaluate
HIV-related complaints that require immediate intervention
- Establish
a strong patient-provider relationship with clear lines of communication
- Initiate
a complete medical database (Table 3-1)
- Assess the
patient's understanding of HIV disease
- Identify
health needs for current medical problems, including those associated
with mental health, substance abuse, hepatitis, and hypertension
- Assess the
need for social and psychological intervention
- Assess the
need for consultants for medical, social, or psychiatric care
- Describe
HIV disease in lay terms, including natural history, laboratory
tests (CD4 cell count and viral load), complications, treatment,
and outcome
- Describe
methods of transmission and of prevention
This is a large
menu, and there may need to be several "first visits."
What are
the important aspects of the initial evaluation in patients with
symptoms?
It is critical
to learn quickly if the patient has any HIV-related complications
that indicate advanced disease and may require rapid intervention.
The most common presentations related to earlier HIV disease are
thrush, weight loss, skin lesions of Kaposi's sarcoma, Pneumocystis
carinii pneumonia (PCP), and fever. Patients with HIV can also have
medical conditions that stem from other causes, such as headaches,
upper respiratory infections (URI), gastroesophageal reflux disease
(GERD), hypertension, diabetes, or heart disease. Distinction between
these and conditions that are HIV-related may be obvious, but when
not, the best laboratory test is a CD4 cell count, which represents
the barometer of immune function with HIV infection. Nearly all
HIV-related complications occur when the CD4 cell count is <200/mm3.
It may take 2-3 days for the laboratory to report the CD4 cell count,
but clues to late-stage disease include evidence of chronic illness
with weight loss and/or fever, and/or a total lymphocyte count of
<1,000 mL which is readily available from a stat complete blood
count (WBC x % lymphocytes). Late-stage HIV also is an indication
of some urgency to initiate antiretroviral therapy. Some patients
present with late complications such as PCP, cryptococcal meningitis,
toxoplasmosis, or cytomegalovirus (CMV) retinitis. When these are
in the differential diagnosis, the workup may require hospitalization,
consultation, extensive testing, and frequent followup by telephone
or clinic visit. These are medical emergencies all are ultimately
lethal and all are treatable.
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).
Table
3-1. Initial History and Physical Examination:
Key Areas for Patients with HIV/AIDS
History
|
HIV-specific
information |
- 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
assessment |
- 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
|
Past
medical history |
- 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
|
Social
history |
- 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
|
Vital
signs, weight, height |
|
Skin |
Dermatitis,
folliculitis, fungal infections, molluscum, and Kaposis sarcoma |
HEENT
|
- Retinal
exam (with CD4 < 200/mm3)
- Oropharynx:
oral hairy leukoplakia, candidiasis, dentition
|
Lymph
nodes |
Cervical,
axillary, inguinal |
Abdomen |
Liver
and spleen |
Neurologic
status |
Special
focus on mental status and sensation |
Genital
and rectal findings |
Discharges,
ulcers, and warts |
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 <200/mm3, and 5)
lethal outcome. Emphasize that without therapy the average untreated
patient survives about 10 years from HIV acquisition to death,
but there is a great deal of individual variation.
- What
does the CD4 cell count mean? This is the cell that becomes
infected with HIV, it is also the quarterback of the immune system,
and the count is a barometer of immunosuppression. Normal is >500/mm3;
a count of <200/mm3 is the
definition of AIDS.
- What
does the viral load mean? This indicates the amount of HIV
in the blood. The average is about 30,000 copies per ml (c/ml),
but again there is a great deal of individual variation. When
it is high, the CD4 cell count tends to decline rapidly (negative
CD4 slope). The goal of therapy is to reduce the viral load to
undetectable levels, and with this the CD4 cell count usually
increases 100-150 cells/mm3
each year.
- 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).
How should
prevention be addressed?
Prevention
needs to be addressed early and frequently, usually at every encounter.
Nearly all adults who acquired HIV after 1985 did so by sexual exposure
or needle sharing in the context of injection drug use. Patients
in HIV clinics now constitute an important source for HIV transmission
by the same mechanisms. Health care providers are now considered
essential in risk reduction with a 3-part responsibility:
- Risk
behavior screening. Patients need to be screened for risk
behaviors. The screening includes a history of sexual practices
and a clinical assessment for evidence of sexually transmitted
diseases (STDs). The history of sexual practices can be taken
before patients are seen by the primary care provider, either
by another staff member or by having patients complete questionnaires.
A component of the assessment includes evaluation for STDs because
having STDs is associated with a 5-fold increase in the risk of
transmitting HIV and also indicates high-risk sexual activities.
Women under 25 years old should be screened for cervical Chlamydia
trachomatis, all symptomatic patients should be evaluated for
gonococcal and chlamydia infection, and asymptomatic patients
should be considered for screening for these pathogens. Screening
is now facilitated by the use of urine specimens for nucleic acid
amplification tests (NAAT) for both N. gonorrhoeae and C. trachomatis.
- Risk
reduction counseling. The second component of prevention is
risk reduction counseling, which may be done in the office or
through referral. It is critical that patients be fully informed
about how HIV is and is not transmitted and that they be counseled
about how they can reduce the risk of transmitting HIV to others.
- Partner
referral.
The third component, partner referral, involves asking patients
to identify persons whom they have placed at risk through sexual
or drug-using behaviors. These persons are then referred to a
"Partner Counseling and Referral Service" (PCRS) without
identifying the source of the information. The PCRS provides public
health resources for confidentially informing partners that they
have been exposed to HIV and need HIV counseling and testing.
For more information
on prevention, see Chapter 2: Approach to the Patient (section on
Risk Assessment and Counseling), Chapter 4: Prevention of HIV in
the Clinical Care Setting, and Chapter 13: Management of Substance
Abuse .
What are
common patient questions?
Patients have
many questions when they are newly diagnosed with HIV.
- What
will happen to me? Patients need to know the facts of HIV
regarding prognosis, but emphasis should be placed on the extraordinary
benefits of therapy, which, for many, may mean a normal lifespan.
- Can HIV
be cured? Not with current drugs (but it can be contained).
- Will
I need to take medicine forever? Patients who respond well
to therapy will probably be able to discontinue treatment periodically,
but regularly scheduled treatment interruptions generally result
in poor long-term control of HIV.
- Would
alternative medicine help me? Probably not, but some patients
seem to think it does. Patients should be encouraged to report
any alternative medicines they are taking because some of them
are problematic in combination with ART.
- Will
I give HIV to the people I live with? Patients can give HIV
to anyone they have sex with or share needles with; however, they
also need to understand that people who live in the same household
without that kind of contact are not at risk. It is probably best
for people with HIV to have their own toothbrushes and razors
and not to share eating utensils that have not been washed, even
though HIV is not generally transmitted that way.
- Are pets
a problem for me? Pets
don't give or get HIV. Occasionally cats will become the source
of Toxoplasma gondii or Bartonella, but this is rare; patients
should wash their hands after handling pets and especially before
eating, avoid contact with cat stool to prevent toxoplasmosis,
and avoid cat bites and scratches and fleas to avoid bartonellosis.
- Should
I have a special diet?
Nutrition is important, but there is nothing idiosyncratic about
the needs of people with HIV (see Table 2-1 in Chapter 2 for nutrition
resources). With late-stage disease, it might be smart to avoid
ingesting lake water because of Cryptosporidium parvum, which
is commonly present and can cause chronic disease.
- Can I
travel? Certain vaccines required for travel to developing
countries are best avoided by people with suppressed immune systems,
but vaccines rarely interfere with travel. The biggest problem
may be access to good health care and the usual conditions such
as traveler's diarrhea that can affect any traveler.
- What
will happen if I am around someone with a cold or some other common
infection? This type of exposure would probably cause nothing
more than an ordinary cold. People with HIV infection do not become
susceptible to infectious complications until the CD4 cell count
is low. Then they become vulnerable to a very specific menu of
infectious disease complications that are extremely rare in the
general public. The infections that are common, such as upper
respiratory infections or gastroenteritis, are generally no worse
in a person with advanced HIV disease than in a healthy person.
- My cousin
has a newborn infant that I want to visit. Is this a good idea?
There should be no reservations here and no reason to talk about
HIV infection. It's okay to hold, kiss, and hug the child; patients
should just obey the simple rules of hygiene that they would under
ordinary circumstances.
- Who should
I tell? People who have been placed at risk either sexually
or through drug use need to know, and either the patient can tell
them or health department staff can do it. The reason is that
they need to be tested so that if they are infected they do not
transmit HIV to others, and they also need to gain access to care,
which is critical. Beyond that, patients should be counseled to
be very careful who they tell about the diagnosis.
- Do I
need to tell people at work? Generally no. HIV is not transmitted
by HIV-infected workers in the work place. A rare exception is
some health care workers who could conceivably transmit HIV infection
during surgery. Most institutions have policies about health care
workers who perform invasive procedures, and these need to be
followed. Otherwise, there are no other circumstances in which
anyone needs to know unless the symptoms of HIV interfere with
effective performance.
What should
be covered in the physical exam?
Everything,
but special attention should be paid to scrutiny of the vital signs,
enlargement of lymph nodes, skin lesions, enlargement of liver or
spleen, and mental status (see Table 3-1).
What are
the initial laboratory tests to order?
Standard laboratory
testing should be done to stage the HIV disease, determine the general
health status, and identify the presence of concurrent conditions,
and baseline tests should be done on patients who are candidates
for ART (see Table 3-2). In general, the CD4 cell count identifies
the need to treat with antiretroviral drugs, and the viral load
is the major indicator of therapeutic response.
Table
3-2. Laboratory Testing in HIV Primary Care
Confirmation
of Positive HIV Status
|
Standard
HIV serologic test |
Either
copy of prior lab results or new tests |
|
|
HIV
Staging
|
CBC |
Yes |
Repeat
at 3-6 month intervals |
|
CD4
count |
Yes |
Repeat
at 3-6 month intervals |
|
HIV
viral load |
Yes |
Repeat
at 3 month intervals |
|
Health
Status Evaluation
|
Chemistry
panel |
Yes |
Repeat
annually |
|
Pap
smear |
Yes |
Repeat
at 6 months and then annually |
PPD
|
Yes
if no history of TB or a prior positive test |
Repeat
if initial test was negative and patient was exposed, or if
CD4 count increased to > 200/mm3 |
Hepatitis
Screen |
HAV |
Optional |
|
|
HBsAg |
|
|
|
anti-HBc
or anti-HBs |
Yes |
|
|
HCV |
Yes |
|
|
STDs |
VDRL
or RPR |
Yes |
Repeat
annually in sexually active patients |
|
Urine
nucleic acid amplification test (NAAT) for N. gonorrhoeae and
C. trachomatis |
Consider
for sexually active patients |
Consider
annual testing or more frequently if at high risk |
|
Chest
x-ray |
Optional |
|
|
Toxoplasma
gondii IgG |
Yes |
|
|
Baseline
for HAART
|
Fasting
glucose |
Yes |
|
Fasting
lipids |
Yes |
|
Ongoing
Care
TOP
After the
initial evaluation is completed, how often do patients need to be
seen?
In general,
patients with early-stage disease are seen at 3-month intervals
to undergo routine medical evaluation and monitoring of CD4 cell
count, viral load, and CBC. During the initial evaluation more frequent
visits are common because there is so much information to transmit.
Visits should also be more frequent when therapy is introduced and
when the CD4 cell count is <200/mm3 because complications are
more likely. It is very important for the primary care provider
to thoroughly understand HIV and its complications. In general,
the patients are in 4 categories with some overlap: 1) those with
a CD4 cell count of >200/mm3, whose complaints are rarely due
to HIV or its complications, 2) patients with a CD4 cell count of
<200/mm3, whose new complaints usually reflect an HIV-related
complication which is usually both potentially serious and treatable,
3) patients from either group who are receiving ART and other medications,
in which case the side effects of the drugs must be considered,
and 4) patients with other medical problems, which is actually the
rule rather than the exception because of the high frequency of
concurrent conditions.
How can
one provider take care of all of the problems?
HIV is generally
a complex disease in patients with complicated lives, lifestyles,
and concurrent conditions. They are best served by a multidisciplinary
team with ancillary services for support regarding case management,
mental health, substance abuse treatment, transportation, and housing
assistance, using the chronic disease model of care. Another model
of care emphasizes patient self-management, with the patient as
the principal caregiver supported by a well-prepared practice team
with a clear division of labor. The patient is linked not only to
the provider unit (the clinic) but also to community-based resources
and support from the larger health care organization.
What needs
to be done in the follow-up evaluations?
Follow-up evaluations
are important to document disease trends and response to therapy
and to assess high-risk behavior. This includes history, physical
exam, and lab tests (see Tables 3-1 and 3-2). In general, the review
needs to be tailored to the specific needs of the patient. Sometimes
the major issue is a concurrent condition such as hepatitis C, mental
illness, or substance abuse requiring resources that are best achieved
with a multidisciplinary approach. For patients who are receiving
ART and prophylactic drugs to prevent opportunistic infections,
heavy emphasis needs to be placed on adherence and drug-related
toxicities as discussed in Chapter 7 or on symptoms related to HIV
complications as discussed in Chapters 8, 9, and 10. Under all circumstances,
it is important to periodically assess the patient's knowledge of
HIV since misconceptions are common and patients are often reluctant
to ask the questions that bother them most. In virtually all encounters,
it is important to emphasize prevention.
In patients
at highest risk for STDs (multiple or anonymous partners, sex in
conjunction with illicit drug use, patients whose partners participate
in these activities, high prevalence of STDs in the area or in the
patient population), STD screening is recommended more frequently
than annually (see Chapter 4).
- The focus
of the first visit is determined by the patient's most immediate
needs.
- The initial
evaluation is complex and usually requires several visits.
- An important
aspect of primary care is answering the patient's questions to
ensure that he or she understands the HIV disease process and
treatment.
- While patients
with early-stage HIV disease can be seen at 3-month intervals
for routine medical evaluation, those receiving ART or with more
advanced disease must be seen more frequently.
- A multidisciplinary
team approach with the patient as primary caregiver is the best
approach to care.
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