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HIV Medicine 2005
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Sven Philip Aries and Bernhard Schaaf

The initial interview

• When, where and why was the positive HIV test performed? Was there a negative test prior to this? What risks has the patient taken in the meantime? The question regarding risks can help in the assessment of potential dangers for the patient in further treatment. In the case of a patient without recognizable risk, the test result may be held in doubt until confirmation is given (see also "Laboratory").
• Where has the patient been recently? This is important because certain germs, which are dangerous for the immunodeficient patient, occur in specific regions. For example, someone who has lived in Hollywood for a lengthy period has a relevant risk of histoplasmosis (which is very rare in Europe).
• What drugs are consumed? Large amounts of alcohol are not only toxic to the liver, but also make adherence more difficult due to loss of control. For smokers, the cardiovascular complications of lipodystrophy during therapy are more threatening.
• Family history of diabetes.
• Tuberculosis among contacts of the patient.

• What previous illnesses, what concomitant illnesses?
• Former treated or untreated infections and STDs, including syphilis and Hepatitis B/C?
• What medications are taken regularly/occasionally?

• What is the social background of the patient? What does he do professionally? What duties does he have to fulfill? What are his priorities? Who knows about his infection? Who will help him when he becomes ill? Who does he talk to about his problems? Does he have any friends who are also infected? Is he interested in getting in touch with social workers or self-help groups?

• The HIV test is checked in a cooperating laboratory. Western blot is only positive if gp41+120/160 or p24+120/160 react. Cross-reactive antibodies, for example in the case of collagenosis, lymphoma or recent vaccination can lead to false-positive test results.
• Complete blood count: 30-40% of all HIV patients suffer from anemia, neutropenia or thrombopenia. Check-up at least every 3-6 months, asymptomatic patients included.
• CD4 cell count at the beginning and every 3-4 months thereafter. Allow for variations (dependent on time of day, particularly low at midday, particularly high in the evening; percentage with less fluctuation; HTLV-1 co-infection leads to higher counts despite existing immunodeficit).
• Electrolytes, creatinine, GOT, GPT, γ-GT, AP, LDH, lipase.
• Blood sugar determination in order to assess the probability of metabolic side-effects when undergoing antiretroviral therapy.
• Lipid profile, as a baseline determination to check the course of metabolic side-effects when undergoing antiretroviral therapy.
• Urine status (proteinuria is often a sign of HIV-associated nephropathy).
• Hepatitis serology: A and B, in order to identify vaccination candidates; C, in order to possibly administer HCV therapy prior to ART; perhaps also G, since this coinfection seems to have a positive effect on the course of HIV infection.
• TPHA test.
• Toxoplasmosis serology IgG. If negative: important for differential diagnosis, if CD4 cell count <150/µl - prevention of infection (no raw meat). If positive: medical prophylaxis if necessary.
• CMV serology (IgG). For the identification of CMV-negative patients. If negative: important for differential diagnosis, then information about prevention (safe sex). In cases of severe anemia, transfusion of CMV-negative blood only. If positive: prophylaxis if necessary.
• Varicella serology (IgG). If negative: in principle, active vaccination with attenuated pathogens is contraindicated, but at >400CD4-cells/µl it is probably safe and perhaps useful.

• Physical diagnosis, including an exploratory neurological examination (incl. vibration sensitivity and mini-mental test).
• Tuberculin skin test according to Mendel Mantoux with 10IE (not Tine stamp test as sensitivity is too low). Positive if greater than 5 mm: give prophylaxis (3 months rifampicin and pyrazinamide is probably best); if negative: repeat examination annually.
• Chest X-ray. Contradictory recommendations, probably only makes sense in case of positive tuberculin skin test or clinical indications of disease of the thoracic organs.
• Sonographic scan of the abdomen. A harmless, informative examination as a baseline finding, but not mentioned in the standard guidelines.
• ECG and pulmonary function test. Simple tests to rule out any cardiovascular and pulmonary disease.
• For women, a PAP smear upon initial diagnosis, after 6 months and then, if negative, once a year. Important because of the approx. 1.7-fold increase in the risk of cervical carcinoma.
• For homosexually active males, an anal PAP smear is recommended every 3 years (due to approx. 80-fold increase in risk of anal carcinoma).
• Especially at low CD4 cell counts (e.g. <200/µl) funduscopy (ophthalmological consultancy!) in order to rule out active CMV retinitis or scars. Advisable in cases of good immune status also (photographic documentation as a baseline).
• Nutritional advice and/or treatment of malnutrition.
• Verifying vaccinations (see chapter on vaccinations).
• Checking the necessity of OI prophylaxis.
• Checking the indication for an antiretroviral therapy.