First Cont(r)act The Initial Evaluation of the HIV infected patient Patrick Willemot 2010 September...
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Transcript of First Cont(r)act The Initial Evaluation of the HIV infected patient Patrick Willemot 2010 September...
First Cont(r)actFirst Cont(r)act
The Initial Evaluation of
the HIV infected patient
Patrick Willemot
2010 September 23
The Initial Evaluation of
the HIV infected patient
Patrick Willemot
2010 September 23
OverviewOverview History
General Health Past Histories Opportunistic Infections
Physical Examination Investigations Health Maintenance
History General Health Past Histories Opportunistic Infections
Physical Examination Investigations Health Maintenance
#1: How did theycome to see you?#1: How did theycome to see you?
Referred by MD? Self-obtained test? Referred by gov’t or insurance? Contact tracing? Transfer of care? (not discussed this time)
Referred by MD? Self-obtained test? Referred by gov’t or insurance? Contact tracing? Transfer of care? (not discussed this time)
#2: Confirm HIV Diagnosis#2: Confirm HIV Diagnosis
HIV Ab ELISA
Confirmatory Western blot
Viral load
p24 antigen - not recommended
HIV Ab ELISA
Confirmatory Western blot
Viral load
p24 antigen - not recommended
Remember to discuss: 4 pointsRemember to discuss: 4 points 1. HIV biology
*transmission (must get into the nitty-gritty)
re-infection risk among seroconcordant partners
mechanism of ARVs and resistance
1. HIV biology *transmission (must get into the nitty-gritty)
re-infection risk among seroconcordant partners
mechanism of ARVs and resistance
Remember to discuss: 4 pointsRemember to discuss: 4 points 2. treatability but incurability
try to normalise it a bit: “like diabetes…”
2. treatability but incurability try to normalise it a bit: “like diabetes…”
NEJM 1998 Mar 26; 338 (13): 853-860.
AIDS 1999 Oct 1; 13 (14): 1933-1942.
Remember to discuss: 4 pointsRemember to discuss: 4 points 3. good prognosis with treatment
HIV ≠ AIDS (usefulness of “AIDS” label debatable)
4. women can bear children safely transmission reduced from 25-30% to <1%
3. good prognosis with treatment HIV ≠ AIDS (usefulness of “AIDS” label
debatable)
4. women can bear children safely transmission reduced from 25-30% to <1%
General HealthGeneral Health Present complaints
Functional Status
Past & present risk behaviours What’s their risk of co-infection? What’s their risk of re-infection? What’s their risk of infecting others?NB: remember to use value-neutral language
Present complaints
Functional Status
Past & present risk behaviours What’s their risk of co-infection? What’s their risk of re-infection? What’s their risk of infecting others?NB: remember to use value-neutral language
Past HistoryPast History A) HIV-associated
OIs, neoplasia B) Non-HIV associated C) STDs D) ARV exposure history
with serial CD4, VL, resistance profiles E) Immunizations
pneumococcal, influenza, viral hep, general
A) HIV-associated OIs, neoplasia
B) Non-HIV associated C) STDs D) ARV exposure history
with serial CD4, VL, resistance profiles E) Immunizations
pneumococcal, influenza, viral hep, general
Risk for Opportunistic InfectionsRisk for Opportunistic Infections
Occupational history
Travel history southwest US states, SE Asia, …
Pets
Occupational history
Travel history southwest US states, SE Asia, …
Pets
Physical ExaminationPhysical Examination Usual
Height & Weight
Dermatologic
Rectogenital, including swabs for SILs
Assessment of cognitive status (MMSE/MoCA)
Usual
Height & Weight
Dermatologic
Rectogenital, including swabs for SILs
Assessment of cognitive status (MMSE/MoCA)
InvestigationsInvestigations CBC, ’lytes, hepatic, renal, pancreatic CD4, VL, resistance profile VDRL, HBV, HCV, Toxoplasma, CMV PPD & CXR G6PD, HLA-B*5701 urinalysis, ECG (stool O+P; strongyloides serology) cervical smear
CBC, ’lytes, hepatic, renal, pancreatic CD4, VL, resistance profile VDRL, HBV, HCV, Toxoplasma, CMV PPD & CXR G6PD, HLA-B*5701 urinalysis, ECG (stool O+P; strongyloides serology) cervical smear
Health MaintenanceHealth Maintenance
partner notification safe(r) sex practices drug rehabilitation/safe(r) use vaccinations (HAV, HBV, influenza,
pneumococcal, general) age-appropriate screening/prevention
partner notification safe(r) sex practices drug rehabilitation/safe(r) use vaccinations (HAV, HBV, influenza,
pneumococcal, general) age-appropriate screening/prevention
Decision to start HAARTDecision to start HAART
Usually not to be taken at first visit… Need a bit more data
CD4, VL and resistance profile decision regarding OI prophylaxis willingness to take medications every day…
Usually not to be taken at first visit… Need a bit more data
CD4, VL and resistance profile decision regarding OI prophylaxis willingness to take medications every day…
SummarySummary
Quite a few data points to cover Your agenda and their agenda may be
different - take your time Remember to address what they’re worried
about will I die can you help me can I have kids?
It may take more than one visit!
Quite a few data points to cover Your agenda and their agenda may be
different - take your time Remember to address what they’re worried
about will I die can you help me can I have kids?
It may take more than one visit!
Questions?
Comments?
Concerns?
Questions?
Comments?
Concerns?