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Initial evaluation of adults with HIV

Initial evaluation of adults with HIV
Literature review current through: Jan 2024.
This topic last updated: Jun 22, 2023.

INTRODUCTION — The goals of the initial evaluation of an adult with HIV are to assess the stage of HIV disease, determine the risk for other infections, identify comorbidities that are associated with HIV infection or relevant to its treatment, and select an antiretroviral regimen. In addition, the initial evaluation is an important time to establish the patient-practitioner relationship and educate the patient about the natural history and management of HIV infection.

This topic discusses the elements of the initial evaluation of patients with HIV. Primary care of the patient with HIV is discussed elsewhere. (See "Primary care of adults with HIV".)

GUIDELINES — In the United States, the HIV Medicine Association of the Infectious Diseases Society of America (IDSA) has published guidelines on the primary care of individuals with HIV, which were last updated in 2020 [1]. The recommendations discussed in this topic are generally consistent with these guidelines.

Links to recommendations by other expert groups, including the European AIDS Clinical Society [2], can be found in the society guideline links topic. (See 'Society guideline links' below.)

ESTABLISHING THE DIAGNOSIS

Patients with a prior history of HIV — In patients who present at their initial visit with a prior history of HIV, efforts should be made to obtain documentation of HIV antibody or HIV RNA testing in the past. If these records are not available, repeat HIV antibody testing should be performed to confirm the diagnosis since cases of factitious HIV infection have been reported [3]. (See 'HIV serology' below.)

Patients with suspected HIV — Patients at high risk for HIV or those with symptoms or signs suggestive of acute or chronic infection should be tested. Routine HIV screening and diagnosis of acute HIV infection are discussed in detail elsewhere. (See "Screening and diagnostic testing for HIV infection" and "Acute and early HIV infection: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

HISTORY — A comprehensive medical history should be performed during the initial visits with a patient with HIV. This should include an assessment of the duration and stage of HIV infection, the presence of comorbidities that might affect prognosis and the choice of antiretroviral therapy (ART), and the presence of epidemiologic factors that increase the risk of HIV transmission and acquisition of other infections. The evaluation should also assess the patient's understanding of his or her illness and issues of transmission. For patients who have already been in HIV care, a detailed assessment of any prior treatment is essential. In a newly diagnosed patient, assessment should also include review of the patient's emotional state and available social supports. Involvement of a specialized social worker (HIV case manager) may be useful in this setting.

For newly diagnosed patients or those re-engaging in care, there has been an emphasis on rapid initiation of ART at the initial visit. To allow for this, certain parts of the history may need to be deferred to a subsequent visit. A more detailed discussion of when to initiate ART is presented elsewhere. (See "When to initiate antiretroviral therapy in persons with HIV", section on 'Timing of treatment'.)

History of infection — During the initial evaluation, the patient's history should include the following specific information:

Risk behaviors for HIV infection and their approximate year of onset

History of opportunistic infections (OIs)

Knowledge of initial and most recent CD4 cell counts and HIV viral load (RNA) results

In patients who have previously received ART, a thorough treatment history, including all prior regimens, CD4 count and viral load responses, and significant side effects and/or long-term toxicities, is important for future treatment considerations. Medical records are often required to confirm treatment histories and to document prior drug resistance testing as well as virologic and immunologic responses to therapy. Patients with newly diagnosed HIV infection should also be asked about any prior use of antiretroviral drugs for prevention. (See "HIV pre-exposure prophylaxis".)

Past medical history — When taking a past medical history, clinicians should focus on the presence of common comorbidities, especially those that might affect the choice of ART or response to it. (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

Viral hepatitis – Coinfections with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) are common in individuals with HIV given the shared routes of transmission. Liver disease tends to progress more rapidly in HIV/HBV- and HIV/HCV-coinfected patients compared with those with HCV or HBV infection alone [4]. Patients with chronic HBV should be on a tenofovir-containing regimen [5-7]. Intention to treat HCV also has implications for antiretroviral drug choice because of adverse drug-drug interactions with some regimens. Patient education regarding routes of acquisition of hepatitis B and C is also important. One study found that many patients who engaged in high-risk behaviors (traumatic sex or injection drug use) did not perceive themselves to be at risk for viral hepatitis [8]. (See "Epidemiology, clinical manifestations, and diagnosis of hepatitis B in patients living with HIV" and "Treatment of chronic hepatitis B in patients with HIV" and "Treatment of chronic hepatitis C virus infection in the patient with HIV".)

Cardiovascular risk factors/disease – The presence of traditional cardiovascular risk factors such as hypertension, diabetes mellitus, and dyslipidemia may influence the choice of ART, as some medications, especially protease inhibitors (PIs), may increase the likelihood of developing glucose intolerance and/or dyslipidemia. Patients with HIV are at increased risk for cardiovascular disease after adjustment for traditional risk factors. (See "Epidemiology of cardiovascular disease and risk factors in patients with HIV" and "Management of cardiovascular risk (including dyslipidemia) in patients with HIV".)

Tuberculosis – A history of tuberculosis (TB) or TB exposure should be sought, and results of prior testing or treatment for latent TB, if any, should be obtained. HIV infection is among the most significant risk factors for reactivation of latent TB, and patients with HIV and a history of latent TB are at high risk for developing active infection in the absence of prophylaxis [9]. Furthermore, HIV infection is a risk factor for accelerated TB progression and extrapulmonary involvement, especially in patients with advanced immune dysfunction [10]. (See "Diagnosis of pulmonary tuberculosis in adults".)

Sexually transmitted infections – A history of sexually transmitted infections (STIs) and their treatment should be elicited, including a history of genital or anal warts and any abnormal cervical or anal cytology tests. STIs are common in patients with HIV given shared routes of transmission and may be associated with greater morbidity. As examples, human papillomavirus (HPV)-related cervical and anal dysplasia is common in patients with HIV, and its incidence is highest in those with advanced immune dysfunction. Similarly, herpes simplex virus (HSV) infection can reactivate more frequently in patients with HIV and a longer duration of symptoms than in immunocompetent hosts. (See "Human papillomavirus infections: Epidemiology and disease associations", section on 'Effect of HIV infection on HPV' and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus in patients with HIV".)

In particular, a history of syphilis should be assessed, as the rate of syphilis has been rising, especially among men who have sex with men (MSM) with HIV [11]. (See "Syphilis in patients with HIV", section on 'Epidemiology'.)

Gynecologic and obstetric history – Females of childbearing age should be asked regarding their current contraceptive practices and any plans for future pregnancy, which may impact ART selection. The results of Papanicolaou (Pap) tests and mammograms, including any abnormal results, should be noted. (See "HIV and women", section on 'Choice of contraception' and "HIV and women", section on 'Abnormal cervical cytology' and "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings".)

Malignancy – In the era of potent ART, there is an increased incidence of non-AIDS-defining malignancies contributing to overall mortality in persons with HIV. Patients should be interviewed about their history of smoking, family history of cancer, and any symptoms of malignancy (eg, weight loss, chronic cough, rectal bleeding). (See "HIV infection and malignancy: Epidemiology and pathogenesis", section on 'Epidemiology'.)

Psychiatric history – Psychiatric disorders, particularly depression, are very common in patients with HIV [12]. Patients should be asked about prior psychiatric diagnoses and be screened for depressive symptoms [13]. (See "Depression, mania, and schizophrenia in patients with HIV".)

Patients should also be asked about any history of trauma. People living with HIV have high rates of sexual and physical abuse and other forms of intimate partner violence. (See "Intimate partner violence: Diagnosis and screening".)

Other comorbidities – Other medical conditions that might influence antiretroviral drug choice include chronic renal insufficiency, peripheral neuropathy, and metabolic bone disease. (See "Overview of kidney disease in patients with HIV" and "Epidemiology, clinical manifestations, diagnosis, and treatment of HIV-associated distal symmetric polyneuropathy (HIV-DSPN)" and "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach", section on 'Additional considerations' and "Selecting antiretroviral regimens for treatment-naive persons with HIV-1: Patients with comorbid conditions".)

Medications and allergies — A complete antiretroviral drug history should be obtained; an HIV medication poster or card can be useful in this context. Medication adherence should be assessed, and any history of drug allergies or drug hypersensitivity should be elicited. (See "Evaluation of the treatment-experienced patient failing HIV therapy", section on 'Assess medication adherence' and "Abacavir hypersensitivity reaction".)

Patients should also be asked about their use of complementary, alternative, and over-the-counter therapies in addition to prescribed medications. Reliable studies examining the safety and efficacy of these therapies are lacking, and potential interactions with antiretroviral drugs (eg, St. John's wort with PIs) are a concern.

Immunization history — A complete immunization history should be obtained, including dates of pneumococcal vaccines, meningococcal vaccines, recombinant zoster vaccine, HPV vaccination, tetanus toxoid, and coronavirus disease 2019 (COVID-19) vaccine. Additionally, a prior history of hepatitis A and hepatitis B vaccines should be sought with documentation of protective antibody response. Although guidelines have been in place since 1999 regarding the importance of hepatitis A and B vaccination among patients with HIV, studies of outpatient HIV clinics continue to document low rates of screening and immunization [14,15]. (See "Immunizations in persons with HIV" and "COVID-19: Vaccines".)

Social history — Elements of the social history should focus on ongoing risk factors for HIV transmission and other exposures that increase the risk of other infections or comorbidities that are common in patients with HIV.

Employment and travel history – It is important to inquire about the employment, housing, and insurance status of the patient. A thorough travel history is also essential. Patients may be at risk for certain reactivation infections (eg, histoplasmosis, coccidioidomycosis) based upon their current and past geographic exposure.

Substance use – A discussion of past and current substance use is extremely important. Ongoing injection drug use can lead to transmission of HIV to others, as well as increase the risk of acquisition of HCV and other blood-borne pathogens. (See "Substance use disorder in patients with HIV".)

A tobacco history should be obtained as well since an increased risk of primary lung cancer in patients with HIV has been reported [16]. One study from Denmark suggested that smokers with HIV lose more life-years to smoking than to HIV [17]. Another study suggested that smokers with HIV who are taking ART are much more likely to die from lung cancer than from AIDS-related conditions [18]. (See "HIV infection and malignancy: Management considerations", section on 'Lung cancer' and "Epidemiology of cardiovascular disease and risk factors in patients with HIV", section on 'Cigarette smoking'.)

Sexual history – Clinicians should ask patients about past and current sexual practices including condom and contraceptive use. Cocaine, crystal methamphetamine, and heavy alcohol use can contribute to high-risk sexual activities and thereby increase the risk of HIV transmission to others [19].

Gender identity Clinicians should avoid assumptions about patients’ gender identity. They should ask patients about their preferred name and gender pronouns. Intake forms and medical records should allow for appropriate documentation of gender identity. (See "Primary care of transgender individuals".)

Family history — A family history of coronary artery disease (specifically in a first-degree relative before the age of 55 years for male relatives and 65 years for female relatives), diabetes mellitus, dyslipidemia, and malignancies should be sought.

Review of systems — The review of systems should elicit any constitutional symptoms, such as fevers, night sweats, and weight loss, as well as localized complaints. Patients with advanced immunosuppression should specifically be questioned about common HIV-related symptoms and signs such as new visual floaters, change in vision, thrush, dysphagia/odynophagia, cough, shortness of breath, diarrhea, skin rash, headache, inability to concentrate, muscle weakness, or paresthesias.

PHYSICAL EXAMINATION — A comprehensive physical examination, including weight and height, should be performed as part of the initial evaluation. Certain physical exam findings are common or important to assess in the patient with HIV, particularly in the setting of advanced immunosuppression:

Skin – Skin findings that have been associated with HIV include seborrheic dermatitis, eosinophilic folliculitis, psoriasis, superficial fungal disease, molluscum contagiosum, herpes simplex, herpes zoster, and Kaposi sarcoma (KS).

Body morphology – Assessment for fat redistribution should be performed in patients who have been treated with older nucleoside reverse transcriptase inhibitors (eg, zidovudine, didanosine, stavudine) with careful notation of areas of fat atrophy (eg, malar atrophy, thinning of extremities or buttocks) or fat deposition (eg, prominent cervicodorsal fat pad, visceral adiposity).

Eyes – Patients with advanced immunosuppression are at risk for cytomegalovirus (CMV) retinitis. We refer patients with CD4 cell counts <50 cells/microL to ophthalmology for dilated funduscopic exam to screen for CMV retinitis. However, the clinical benefit of this practice in asymptomatic patients has not been proven. (See "Pathogenesis, clinical manifestations, and diagnosis of AIDS-related cytomegalovirus retinitis".)

Oral mucosa – The oral mucosa should be examined for evidence of candidiasis, oral hairy leukoplakia, aphthous ulcerations, herpes simplex virus (HSV) infection, mucosal KS, angular cheilitis, and periodontal disease. (See "Oral lesions".)

Lymph nodes – Generalized lymphadenopathy attributable to follicular hyperplasia has been described with HIV infection, but asymmetric, bulky, or rapidly enlarging adenopathy may represent malignancy or disseminated infection, especially in patients with constitutional symptoms or advanced immune dysfunction.

Anogenital examination – An anogenital examination should be performed to evaluate for evidence of STIs, including syphilis, gonorrhea, chlamydia, HSV, human papillomavirus (HPV), chancroid, and lymphogranuloma venereum. Candidal vaginitis, bacterial vaginosis, and trichomonas infections are also common in females with HIV. (See "Screening for sexually transmitted infections" and "HIV and women", section on 'Gynecologic issues'.)

Neurologic examination – A neurologic examination should be performed looking for evidence of peripheral neuropathy, asymptomatic muscle weakness, or other abnormalities. There should also be a clinical assessment of cognitive function (eg, mini-mental status exam). If there is concern for significant impairment, formal neuropsychologic testing should be ordered. (See "HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis".)

INITIAL LABORATORY TESTING — Initial laboratory testing should include assessment of HIV staging parameters (CD4 cell count, HIV RNA, HIV genotype test), along with baseline testing of organ function and testing for potential coinfections, such as viral hepatitis (table 1).

HIV-related testing

HIV serology — If prior results demonstrating evidence of HIV infection (HIV antibody or viral load testing) are unavailable and the viral load upon presentation is expected to be undetectable (the patient is taking antiretroviral agents), serologic testing is warranted to establish the diagnosis. Serologic testing algorithms for HIV are discussed in detail elsewhere (table 1). (See 'Patients with a prior history of HIV' above and "Screening and diagnostic testing for HIV infection", section on 'Testing algorithm'.)

CD4 cell count and percentage — Patients with HIV should have a CD4 count and CD4 cell count percentage performed at initiation of care. This information is used primarily to determine the risk of HIV-related complications and the need for prophylactic therapy to prevent opportunistic infections [1].

The CD4 cell percentage (CD4 cell count/total lymphocyte count) tends to have less variation between measurements than the CD4 cell count and may better assess immune function in certain clinical circumstances, including splenectomized patients, patients with a CD4 count >350 cells/microL, and patients with liver disease [20,21]. A CD4 cell percentage of 14 to 29 percent generally corresponds to a CD4 cell count of 200 to 500 cells/microL. (See "Techniques and interpretation of measurement of the CD4 cell count in people with HIV".)

Measurement of the CD8 cell count and the ratio of CD4 to CD8 cells is unnecessary, as the results are not used in clinical decision-making [1].

Viral load — A baseline plasma viral load should be performed upon initiation to care. For some patients, it may affect the selection of antiretroviral regimen (ie, certain drugs should not be used in patients with high HIV RNA levels [ie, >100,000 copies/mL]) and is used to assess response to antiretroviral therapy (ART). (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach" and "Patient monitoring during HIV antiretroviral therapy".)

Resistance testing — HIV genotype testing for mutations in the viral reverse transcriptase and protease associated with antiretroviral drug resistance is recommended for all patients with HIV entering care, regardless of whether ART is initiated [1,6]. This should be performed as soon as possible, ideally during acute or early infection. Resistance testing for integrase strand transfer inhibitors (INSTIs) is not routinely required in treatment-naïve patients unless the source is known or suspected to have INSTI treatment failure or resistance, or the patient acquired HIV after receipt of long-acting cabotegravir (CAB-LA) as pre-exposure prophylaxis (PrEP). (See "HIV pre-exposure prophylaxis", section on 'Injectable therapy (cabotegravir LA)'.)

In the United States, the risk that transmitted virus will be resistant to at least one antiretroviral drug is between 6 and 16 percent depending upon geographic location [22]. Performing resistance testing early in the course of disease increases the chance of detecting transmitted viral mutations before they mutate back to the more fit wild-type virus and decrease to a level lower than the limit of detection of standard genotypic tests.

Resistance testing is also indicated in initial evaluation of patients on ART with a viral load that is not suppressed or has become detectable. Ideally, resistance testing should be done while the patient is taking the failing regimen or within four weeks of discontinuing treatment. In such cases, additional testing beyond genotypic resistance testing may be appropriate, including:

A separate genotype for integrase mutations should be ordered for patients failing an integrase inhibitor-based regimen.

Phenotypic testing can be helpful in a patient who is highly treatment-experienced and has a history of multiple resistance mutations.

Drug resistance testing is discussed in detail elsewhere. (See "Overview of HIV drug resistance testing assays" and "Evaluation of the treatment-experienced patient failing HIV therapy", section on 'Initial evaluation'.)

Additional tests to inform ART selection — Prior to initiating certain antiretroviral agents, screening tests may be necessary to evaluate for potential adverse reactions and drug activity:

HLA-B*5701 testing should be performed before initiating abacavir therapy. Patients who are positive for the HLA B*5701 haplotype are at high risk for hypersensitivity reaction and should not take this drug.

Tropism testing should be performed if the use of a CCR5 antagonist is being considered.

General blood and urine testing — Assessment of the blood count and chemistries is important to evaluate for complications that may be associated with HIV infection or to identify underlying comorbidities that may affect the choice of ART (table 1). Considerations prior to the selection of ART are discussed in detail elsewhere. (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach", section on 'Considerations prior to initiating treatment'.)

Complete blood count — A complete blood count (CBC) with differential count should be obtained. Anemia, leukopenia, lymphopenia, and thrombocytopenia are found in 30 to 40 percent of patients who present with advanced HIV disease [23]. These cytopenias may represent bone marrow suppression, which can occur due to infiltrative infections (eg, Mycobacterium avium complex [MAC] or untreated HIV infection), medications (eg, zidovudine), nutritional deficiencies (eg, vitamin B12), or other factors. (See "HIV-associated cytopenias".)

The CBC on initial evaluation also serves as a baseline to evaluate for hematotoxicity of subsequent ART or other therapeutic agents.

Renal function — Serum creatinine (with calculation of the estimated creatinine clearance) and a urinalysis should be obtained to evaluate for renal dysfunction. This is particularly important among individuals who are at increased risk of renal disease, such as Black individuals, have advanced HIV-disease, or have certain comorbid conditions (eg hypertension, diabetes mellitus). The presence of renal dysfunction also affects the selection of ART regimen (eg, tenofovir disoproxil fumarate [TDF] is not recommended in the setting of a decreased creatinine clearance, ie <60 mL/min/1.73 m2 [24]). Those with renal dysfunction or more than trace proteinuria warrant additional evaluation. (See "Overview of kidney disease in patients with HIV", section on 'Causes of CKD in patients with HIV' and "Overview of kidney disease in patients with HIV", section on 'Diagnosis and management of CKD in patients with HIV'.)

Changes in renal function are used to monitor for drug toxicity.

Hepatic function — Hepatic function should be evaluated through serum aminotransferase and bilirubin levels. Serum aminotransferases may be increased in patients with chronic viral hepatitis, drug-induced liver injury, or steatohepatitis. Synthetic function in a patient with suspected cirrhosis or decompensated liver disease is best assessed with measurements of serum albumin and prothrombin time. Significant hypoalbuminemia may also be seen among untreated AIDS patients with cachexia, HIV-associated nephropathy, malignancy (eg, Kaposi sarcoma [KS]), enteropathy, or systemic illness (eg, tuberculosis [TB]) [25,26].

Liver biochemical and function tests on initial evaluation also serve as a baseline to evaluate for hepatotoxicity of subsequent ART or other therapeutic agents.

Glucose and lipid profile — A random or fasting blood glucose and lipid panel should be obtained to determine if a patient has any baseline metabolic abnormalities and to calculate cardiovascular risk. If random testing is abnormal, fasting samples should be obtained. In addition to identifying an underlying disorder that may warrant therapy, this information can also influence ART drug selection. (See "Management of cardiovascular risk (including dyslipidemia) in patients with HIV", section on 'Role of antiretroviral therapy'.)

Urine pregnancy test — A urine pregnancy test should be performed in people of childbearing potential.

Screening for coinfections — All patients with HIV should undergo laboratory testing for a number of other infections to assess immunity (and the need to immunize, if not immune) and to identify latent or asymptomatic infections that may warrant treatment or prophylaxis against reactivation (table 1).

Viral hepatitis — All patients with HIV should be screened for hepatitis A, B, and C virus infections. Screening and diagnosis of these infections are discussed in detail elsewhere. Briefly, the following tests should be performed:

Hepatitis A virus (HAV) IgG antibody.

Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and antibody to hepatitis B total core antigen (anti-HBc or HBcAb); further evaluation is warranted if the HBsAg is positive or if only the HBcAb is positive. (See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Chronic HBV infection' and "Hepatitis B virus: Screening and diagnosis in adults", section on 'Occult HBV infection'.)

Hepatitis C antibody; a reactive antibody test should be followed by confirmatory HCV RNA testing to establish the presence of active infection. In some cases, initial screening with HCV RNA may be indicated. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Diagnosis'.)

For those who are not immune to HAV or HBV (HAV IgG nonreactive and HBsAb negative), immunization is warranted. (See "Immunizations in persons with HIV", section on 'Hepatitis A vaccine' and "Immunizations in persons with HIV", section on 'Hepatitis B vaccine'.)

Indications for ongoing screening for HCV are discussed elsewhere. (See "Primary care of adults with HIV", section on 'Viral hepatitis'.)

Management of these infections are discussed elsewhere. (See "Treatment of chronic hepatitis B in patients with HIV" and "Treatment of chronic hepatitis C virus infection in the patient with HIV".)

Tuberculosis — All patients with HIV should be screened for TB with PPD testing or interferon gamma testing unless they have a prior documented history of TB or a positive screening test [1]. In patients with a CD4 count <200 cells/microL who have a negative test result, screening should be repeated once they have achieved immune reconstitution. Screening for latent TB in the setting of HIV infection is discussed elsewhere. (See "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

A chest x-ray to rule out active TB should be performed in patients with a positive screening test and in those individuals who are close contacts of persons with infectious TB (regardless of the results of the screening test). Both groups should be treated for latent TB once active disease has been excluded. (See "Treatment of tuberculosis infection (latent tuberculosis) in nonpregnant adults with HIV infection".)

Indications for repeat testing for TB are discussed elsewhere. (See "Primary care of adults with HIV", section on 'Tuberculosis'.)

Sexually transmitted infections — Sexually transmitted infections (STIs) are common in patients with HIV given shared routes of transmission, can be associated with considerable morbidity, and some may be asymptomatic. Thus, individuals with HIV should undergo laboratory screening for syphilis, gonorrhea, and chlamydia; persons with HIV who engage in vaginal sex should also be tested for trichomonas. Diagnostic testing for these infections is discussed in detail elsewhere (see "Screening for sexually transmitted infections"). Briefly, the following tests should be performed:

Syphilis – Testing for Treponema-specific antibody (eg, enzyme immunoassay) followed by a nontreponemal test if the initial test is positive or a nontreponemal serologic test (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL] test) followed by a treponemal test (eg, fluorescent treponemal antibody absorption) if the initial test is positive. The order of testing depends upon the algorithm used by the laboratory. Further evaluation for neurosyphilis (eg, with lumbar puncture) is warranted in patients with reactive serology who have neurological symptoms or signs. (See "Syphilis: Screening and diagnostic testing" and "Syphilis in patients with HIV", section on 'Diagnosis'.)

Gonorrhea and chlamydia – Nucleic acid amplification tests (NAATs) for Neisseria gonorrhoeae and Chlamydia trachomatis. Preferred specimens are a vaginal or cervical swab in females and a urine sample (preferably first-catch) in males. Individuals who report receptive anal intercourse should provide a rectal sample for NAAT for both organisms. Individuals who report receptive oral intercourse should provide a pharyngeal sample for NAAT for N. gonorrhoeae. (See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Diagnosis of chlamydial infections' and "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Diagnostic approach'.)

Trichomonas – NAAT for Trichomonas vaginalis of a vaginal swab. (See "Trichomoniasis: Clinical manifestations and diagnosis".)

Indications for retesting and ongoing screening for these infections are discussed elsewhere. (See "Primary care of adults with HIV", section on 'Sexually transmitted infections' and "Screening for sexually transmitted infections", section on 'Patients with HIV infection'.)

Management of these infections is also discussed elsewhere. (See "Syphilis in patients with HIV" and "Treatment of Chlamydia trachomatis infection" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

Additional considerations — Screening for certain infections should only be performed in select settings.

Cryptococcal antigen – Screening for cryptococcal antigen (CrAg) is reasonable in asymptomatic patients with a CD4 count ≤100 cells/microL who are not receiving effective ART. There may also be a benefit to screening at a higher CD4 count threshold (eg, <200 cells/microL) in certain areas of high prevalence for cryptococcal disease. This approach is consistent with several guideline panels [1,7,27] and is discussed in detail elsewhere. (See "Cryptococcus neoformans meningoencephalitis in persons with HIV: Treatment and prevention", section on 'Screening and treatment of early infection'.)

Cytomegalovirus – For most patients, screening for prior cytomegalovirus (CMV) is not warranted since many patients will have detectable antibody and no action is needed. However, obtaining a CMV IgG antibody titer may be helpful in patients who require transfusions, since they should receive CMV-negative or leukocyte-reduced blood products. (See "Epidemiology, clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults", section on 'Transmission'.)

Toxoplasma – A Toxoplasma IgG antibody titer should be performed in patients with a low CD4 count (eg, <200 cells/microL) to identify patients at potential risk for reactivation infection. Relapse of latent infection occurs in 20 to 47 percent of patients with HIV and a CD4 cell count of <100 cells/microL who have not received prophylactic antibiotics and have positive Toxoplasma serology [28]. Patients who are seronegative should be counseled on how to avoid new infection, such as avoidance of eating undercooked meat and precaution with handling soil or material contaminated with cat feces. (See "Toxoplasmosis in patients with HIV".)

Measles, mumps, and rubella – All persons should be assessed for immunity to measles, mumps, and rubella (MMR). Evidence of immunity includes written documentation of prior vaccination, laboratory evidence of immunity or disease, or birth in the United States before 1957. Vaccination is indicated for those without evidence of immunity, unless the patient has evidence of severe immunosuppression (eg, CD4 percentage <15 percent or a CD4 count <200 cells/microL). (See "Immunizations in persons with HIV", section on 'Measles, mumps, and rubella vaccine'.)

Varicella-zoster virus – We check a varicella-zoster virus (VZV) IgG antibody titer in those patients without a clear history of chickenpox or prior vaccination. Knowledge of immunity informs the need for strategies (eg, vaccination versus varicella-zoster immune globulin) to reduce the risk of infection. (See "Post-exposure prophylaxis against varicella-zoster virus infection" and "Immunizations in persons with HIV", section on 'Varicella vaccine'.)

Screening for HPV-associated neoplasia — HIV infection is associated with an increased prevalence of human papillomavirus (HPV) infection and a higher rate of HPV-associated neoplasia. Thus, screening for these is warranted in high-risk groups.

Cervical cancer — Cervical cancer screening should be performed as part of the initial evaluation in all females with HIV. The type (eg, Papanicolaou [Pap] testing, co-testing [ie, HPV testing plus Pap testing]) and frequency of screening are discussed in detail elsewhere. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states" and "HIV and women".)

Anal cancer — HIV infection is associated with an increased risk for anal neoplasia in males and females regardless of sexual orientation [29,30]. Screening for anal intraepithelial neoplasia can be done through anal cytology examination (anal Pap test). We advise screening individuals with HIV when there is local expertise in cytologic result interpretation and availability of a referral structure for high-resolution anoscopy with biopsy, as well as ablative treatments and follow-up. Because of the low incidence of anal cancer among younger individuals with HIV, some UpToDate contributors advise deferring screening until after 30 years of age. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

This practice is slightly different from the HIV Medicine Association (HIVMA)/Infectious Diseases Society of America (IDSA) recommendations to screen for anal cancer in the following populations with HIV [1]:

Individuals with a history of receptive anal intercourse

Females with a history of abnormal cervical Pap smear

Individuals with genital warts

Patients with any abnormality on an anal Pap test should be referred for high-resolution anoscopy and biopsy. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'High-resolution anoscopy' and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Our recommended approach to treatment'.)

Select testing

G6PD deficiency — Screening for glucose-6-phosphate dehydrogenase (G6PD) deficiency should be performed in patients belonging to African, Asian, or Mediterranean populations before initiating therapy with dapsone (used for prophylaxis and/or treatment of Pneumocystis jirovecii) or primaquine (an antimalarial), as these drugs can precipitate hemolysis in G6PD deficient patients. Some experts also screen for G6PD deficiency in those starting sulfonamides (eg, trimethoprim sulfamethoxazole) [1]. A detailed discussion of G6PD deficiency is presented in a separate topic review. (See "Diagnosis and management of glucose-6-phosphate dehydrogenase (G6PD) deficiency", section on 'Clinical manifestations'.)

Bone mineral density testing — Although supporting data are limited, baseline bone densitometry screening for osteoporosis in patients with HIV is advised in postmenopausal females and males aged 50 years of age or older [1]. Management of osteoporosis consists of ruling out secondary causes (eg, hypogonadism, vitamin D deficiency, hyperparathyroidism, thyroid disease), initiating lifestyle changes (eg, increased physical activity, smoking cessation), calcium and vitamin D supplementation, and bisphosphonate therapy. (See "Bone and calcium disorders in patients with HIV".)

EVALUATION FOR ANTIRETROVIRAL THERAPY — The goals of antiretroviral therapy (ART) are to prolong life and improve its quality, restore and preserve immunologic function (as measured by CD4 count), maximally and durably suppress the HIV viral load, and prevent HIV transmission [6]. Although cure of HIV infection is not achievable with current management approaches, ART has resulted in significant reductions in HIV-related morbidity and mortality.

ART is recommended for all individuals with HIV regardless of CD4 cell count, and ART should be initiated as soon as possible after HIV diagnosis [6,7]. The initial evaluation is a time to educate the patient about ART, including the benefits for the patient’s own health and for prevention of transmission, and to evaluate for potential issues with medication adherence.

Some of the findings on history and initial laboratory testing can inform decisions regarding the choice of ART regimen; however, except for pregnancy status, most of this information does not need to be known prior to initiating one of the preferred regimens that include tenofovir-emtricitabine with either dolutegravir or bictegravir.

Initiation, management, and monitoring of ART are discussed in detail elsewhere:

(See "When to initiate antiretroviral therapy in persons with HIV".)

(See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

(See "Selecting an antiretroviral regimen for treatment-experienced patients with HIV who are failing therapy".)

(See "Patient monitoring during HIV antiretroviral therapy".)

PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS — Primary prevention of opportunistic infections can be stratified by CD4 count. Prophylactic antibiotics for primary prevention of opportunistic infections should be given to patients with CD4 cell counts <200 cells/microL. Complete information on dosing regimens and alternative therapeutic agents is discussed elsewhere. (See "Overview of prevention of opportunistic infections in patients with HIV" and "Mycobacterium avium complex (MAC) infections in persons with HIV" and "Treatment and prevention of Pneumocystis infection in patients with HIV".)

RISK REDUCTION COUNSELING — Behavioral risk reduction counseling is an important part of the management of patients with HIV. This is discussed in detail elsewhere. (See "Primary care of adults with HIV", section on 'Behavioral risk reduction counseling'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in persons with HIV" and "Society guideline links: Primary care of adults with HIV".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: HIV/AIDS (The Basics)" and "Patient education: Starting treatment for HIV (The Basics)" and "Patient education: Tests to monitor HIV (The Basics)")

Beyond the Basics topics (see "Patient education: Testing for HIV (Beyond the Basics)" and "Patient education: Initial treatment of HIV (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Goals of the initial evaluation – The goals of the initial evaluation of an adult with HIV are to assess the stage of HIV disease, determine the risk for other infections and the need for prophylaxis, identify comorbidities that are associated with HIV infection or relevant to its treatment, and select an antiretroviral regimen. (See 'Introduction' above and 'Evaluation for antiretroviral therapy' above and 'Prophylaxis of opportunistic infections' above.)

History – A comprehensive medical history should be performed during the initial visits with a patient with HIV. This should include discussion of risk factors for and history of HIV, any prior treatment history, and the presence of potential comorbidities that are common in populations with HIV, such as viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB), as well as risk factors for cardiovascular disease. The evaluation should also assess the patient's understanding of his or her illness and issues of transmission. (See 'History' above.)

Physical examination – The physical examination should be attentive to potential complications that can occur in patients with advanced immunosuppression (eg, thrush) or with long-standing HIV (eg, fat redistribution). In particular, examination of the skin, oral mucosa, lymph nodes, and anogenital region is often revealing in patients with advanced HIV. (See 'Physical examination' above.)

Laboratory testing – Initial laboratory testing should include assessment of HIV staging parameters (CD4 cell count, HIV RNA, HIV genotype test) along with baseline testing of organ function and screening for potential coinfections, such as viral hepatitis, TB, and STIs, including human papillomavirus (HPV)-related neoplasia (table 1). (See 'Initial laboratory testing' above.)

Selecting an antiretroviral regimen – Antiretroviral therapy (ART) is recommended for nearly all persons with HIV, regardless of the CD4 cell count. The initial evaluation is a time to educate individuals about ART and evaluate for readiness and potential issues with medication adherence. Detailed discussions of selecting an ART regimen are presented in separate topic reviews. (See "When to initiate antiretroviral therapy in persons with HIV" and "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

ACKNOWLEDGMENT — UpToDate gratefully acknowledges John G Bartlett, MD (deceased), who contributed as Section Editor on earlier versions of this topic and was a founding Editor-in-Chief for UpToDate in Infectious Diseases.

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Topic 3741 Version 45.0

References

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