History-taking for patients with HIV requires attention to all of the elements standard in primary care while including several additional elements, which are detailed in Table 1, below. It is essential to identify, assess, and monitor HIV- and antiretroviral therapy (ART)-related complications and other HIV-specific comorbidities (see Box 1: Conditions With Higher Incidence in People With HIV and Selected Citations).
A comprehensive baseline history includes sexual health, mental health, substance use (including illicit use of prescription drugs), and social history. Patients may choose not to disclose all pertinent personal information during the first visit, but a sympathetic and nonjudgmental attitude can help establish trust and facilitate further discussion and disclosure during subsequent visits.
HIV-Specific Medical History
Essential components of an HIV-specific medical history are detailed in this section and in Table 1, below. Confirmation of a patient’s HIV infection should include documented laboratory testing results. If results are not available, baseline testing should be performed as noted in Table 1, below. If a patient was recently diagnosed with HIV, discussion of the reasons for testing and the route of exposure will assist the clinician in identifying appropriate goals for risk reduction education, counseling, and intervention, which may include ongoing screening for sexually transmitted infections (STIs).
Essential components of an HIV-specific medical history:
Viral load and CD4 cell count at diagnosis, if known
Patient circumstances at time of diagnosis (housing, employment, food security, relationship status, etc.)
ART history, including previous regimens, reasons for any changes in prior regimens, and any adverse effects
Pauses in ART and lapses in adherence
Previous resistance testing results
History of opportunistic infections
History of HIV-related hospitalization(s)
Disclosure status (whether partners, family, or friends are aware of HIV status) and partner notification
History of other STIs with shared risk factors, including hepatitis B virus (HBV) and hepatitis C virus (HCV)
Ongoing high-risk behaviors for transmission of HIV and acquisition of STIs or infections associated with injection drug use
Experience of stigma and social support
ART history: Essential elements of an ART history include all previous medications, why they were stopped, and reasons for stopping (e.g., allergies, adverse effects, pill-taking fatigue or discomfort, and drug resistance). Understanding these reasons and seeking ways to simplify ART regimens or reduce pill burden will support a therapeutic alliance around adherence going forward.
ART initiation: If a patient with HIV has not yet started ART, it should be initiated as soon as appropriate and possible, and any barriers to ART initiation should be assessed so support can be provided.
Trauma-informed care: A trauma-informed approach to care is important to mitigate any medical trauma, such as frightening experiences or stigma associated with the initial HIV diagnosis [Tang, et al. 2020; Sherr, et al. 2011]. See the following for more information:
Adherence: For patients already taking ART, assessing adherence and providing support for optimal adherence are crucial and should include careful assessment of adverse medication effects, which often lead to adherence problems or medication cessation. Other factors to discuss that may pose barriers to adherence include insurance coverage, housing instability, disclosure status, substance use, and mental health.
Viral hepatitis status: Many of the risk factors for acquisition of viral hepatitis are the same as those for HIV. Assessment of a patient’s viral hepatitis status, including a history of viral hepatitis infection and treatment, helps clinicians determine optimal treatment options. In individuals with HIV, progression of HBV- or HCV-associated liver fibrosis, cirrhosis, cancer, portal hypertension, and encephalopathy is more rapid than in those without HIV [Weber, et al. 2006; Thio, et al. 2002; Graham, et al. 2001; Benhamou, et al. 1999].
HCV: Because the risk of severe liver disease is increased in patients with HIV [Soti, et al. 2018], all patients with HCV and HIV should be treated for HCV infection as soon as possible. Potential interactions between ART and HCV medications should be identified and addressed. Treatment of chronic HCV is the same for individuals with and without HIV.
HBV: A history of HBV infection will influence HIV medication choice and requires attention to drug-drug interactions. Because tenofovir, emtricitabine, and lamivudine are effective against both HBV and HIV, it is important to assess baseline HBV status and choose combination HIV therapy to appropriately treat the HBV infection as well as HIV. It is also important to appropriately monitor for progression of fibrosis or hepatocellular carcinoma; however, ART initiation should not be delayed pending evaluation of HBV status and liver damage. See the NYSDOH AI guideline Prevention and Management of Hepatitis B Virus Infection in Adults With HIV.
General Medical Status, History, and Physical Examination
This guideline assumes that care providers are familiar with performing a comprehensive physical examination. Several areas may require additional attention because the incidence, associated complications, or severity may be increased in individuals with HIV or low CD4 cell counts.
Medications: Ideally, a complete medication history should be acquired at baseline and updated as needed during future visits. A detailed medication history (with emphasis on ART) allows the clinician to identify possible adverse drug-drug interactions between ART and medications the patient is taking to treat comorbidities (see Box 1: Conditions With Higher Incidence in People With HIV and Selected Citations). Patients with HIV may have multiple comorbidities due to infection and related inflammatory processes or the effects of medications. Examination of a patient’s current medical status and medication regimen may identify the need for changes in the ART regimen, changes in medications prescribed for other medical conditions, options for simplification of medication regimens, and medications that may be discontinued (see the NYSDOH AI guideline Selecting an Initial ART Regimen > Special Considerations for Comorbid Conditions).
Metabolic changes: There are significant metabolic concerns for people with HIV and AIDS [Mankal and Kotler 2014]. Weight gain often occurs after initiation of ART. Assessing weight loss or gain at every visit will assist with early identification of metabolic changes [Bourgi(b), et al. 2020]. Female gender, Black race, pre-ART CD4 cell count depletion, and lower pre-ART body mass index have been associated with >10% weight gain at 2 years after ART initiation [Bourgi(b), et al. 2020]. Integrase strand transfer inhibitors (dolutegravir, bictegravir, raltegravir, elvitegravir, and cabotegravir) have been associated with greater weight gain than non-nucleoside reverse transcriptase inhibitors or protease inhibitors, particularly when used in combination with tenofovir alafenamide [Sax, et al. 2020]. Weight loss is more common in individuals with low CD4 cell counts and may prompt investigation of malignancy, infection, and psychosocial instability.
Head, eyes, ears, nose, and throat: An ophthalmologic examination at baseline and at least annually thereafter is indicated for patients with a CD4 count <50 cells/mm3. Cytomegalovirus (CMV) infection can lead to retinitis, vision loss, and death. Varicella zoster virus and herpesvirus infections can lead to retinitis and retinal necrosis [Nakamoto, et al. 2004]. After the introduction of highly active ART, the 10-year cumulative incidence for CMV retinitis was 33.6% for individuals with CD4 counts <50 cells/mm3 and 4.2% for those with CD4 counts <200 cells/mm3 [Sugar, et al. 2012]. Icterus may be present in individuals who are taking atazanavir as part of their ART regimen by causing a benign hyperbilirubinemia [Bertz, et al. 2013]. HIV viremia can also lead to a direct retinopathy at high viral loads and low CD4 cell counts [Jabs 1995].
Although HIV infection itself does not increase the likelihood of viral upper respiratory infections, symptoms such as cough, sinusitis, and otitis are common in patients with HIV [Brown, et al. 2017; Chiarella and Grammer 2017; Small and Rosenstreich 1997]. Because sinusitis and otitis can present without significant facial pain or discomfort in patients with CD4 counts <50 cells/mm3, it is reasonable to perform imaging and evaluate for infection with atypical organisms, such as fungal sinusitis, more readily in these patients.
People with HIV also have a higher risk of oral malignancies than those without HIV, and those with low CD4 cell counts may have diverse oropharyngeal findings, including oral Kaposi sarcoma, oral candidiasis, human papillomavirus (HPV)- and HIV-related parotitis, and necrotizing gingivitis, requiring evaluation during in-person examinations [Trevillyan, et al. 2018; Sorensen 2011; Epstein 2007]. Clinicians should encourage patients to have annual dental examinations (see National Institute of Dental and Craniofacial Research > HIV/AIDS & Oral Health).
Heme/lymph: Lymphadenopathy may occur at any stage of HIV disease, does not always correlate with disease progression or prognosis, and may be less pronounced in older patients. However, widespread, firm, or asymmetrical lymphadenopathy requires prompt consideration of lymphoma, syphilis, tuberculosis (TB), mycobacterium avium-intracellulare infection, and lymphogranuloma venereum, all of which can occur regardless of CD4 cell count but are more likely at lower CD4 cell counts. Nonadherence to ART may also be considered.
Diffuse large B-cell lymphoma, Burkitt lymphoma, and primary central nervous system lymphoma are AIDS-defining conditions; lymphoproliferative diseases, such as Castleman disease, should be considered as well. Any evidence of lymph nodes larger than 1 cm or evidence of fixed, matted, or hard nodes should prompt consideration for biopsy, particularly if a patient has a low CD4 cell count.
Dermatologic: An annual comprehensive skin examination ensures that concerns are identified early. Regardless of CD4 cell count, findings such as shingles and psoriasis are more frequent in people with HIV than in those without HIV [Alpalhão, et al. 2019; Erdmann, et al. 2018]. For more information, see National HIV Curriculum > Cutaneous Manifestations.
Attention should be paid to any dermatologic history, such as a history of skin cancers and recurrent rash, which could be consistent with psoriasis, seborrheic dermatitis, atopic dermatitis, eosinophilic folliculitis, or secondary syphilis [Alpalhão, et al. 2019; Green, et al. 1996]. Symptoms can overlap and coexist.
Less common diseases, such as Kaposi sarcoma, eosinophilic folliculitis, disseminated zoster, molluscum contagiosum, and cutaneous HPV, may occur in patients with low CD4 cell counts. Familiarity with these diseases is important.
Neurologic: As noted in Table 1, below, clinicians should examine patients’ neurologic and cognitive function at baseline, at least annually for those at risk (due to low CD4 cell count, age, or comorbidities) and more often if there are patient or family concerns. Several standardized tests are available, including the MoCA Test (requires an account), Mini-Cog, and Mini-Mental State Examination (MMSE).
Compared with patients who have higher CD4 cell counts, patients with low CD4 cell counts may be at increased risk for neurologic conditions, which can include rare diseases, such as progressive multifocal leukoencephalopathy, HIV-associated neurologic disease, toxoplasmosis, and cryptococcal meningitis, and common diseases with atypical presentation, such as syphilis and TB.
Imaging and diagnostic work-up are warranted for new or persistent neurologic symptoms (e.g., seizure, changes in mental status, or persistent headache) regardless of CD4 cell count, but especially in patients with a low CD4 cell count.
Respiratory: Clinicians should perform a lung examination at baseline and at least annually, or more often if indicated. Community-acquired pneumonia is more common in people with HIV, regardless of CD4 cell count, than in those without HIV [Almeida and Boattini 2017], as is chronic obstructive pulmonary disease [Bigna, et al. 2018]. Chronic lung disease is increasingly common among older people with HIV, among smokers, and among those who have had Pneumocystis jiroveci pneumonia (PJP; formerly known as Pneumocystis carinii pneumonia or PCP), who may have residual blebs that can lead to pneumothorax [Risso, et al. 2017].
In patients with low CD4 cell counts who have respiratory examination findings or symptoms, clinicians should perform a chest radiographic or computerized tomography to evaluate for infection or neoplasm [Yee, et al. 2020]. Clinicians should also maintain a low threshold for suspicion of TB and pursue appropriate diagnostic and public health measures if TB is suspected.
Comorbidities: For patients with comorbidities, such as cardiovascular disease, lung disease, renal disease, diabetes mellitus, and malignancies, personal and family history should be collected, and individual risk factors should be discussed. Because HIV has been associated with increased risk and accelerated disease process for these comorbidities, care providers should be sure to discuss appropriate screening and have a low threshold for diagnostic testing referral if symptoms develop [Kaspar and Sterling 2017; Triant 2013; Islam, et al. 2012; Shiels, et al. 2011; Bower, et al. 2009; Crothers, et al. 2006]. In individuals taking ART, risk factors such as smoking and hypertension cause more morbidity and mortality than HIV-specific risk factors, such as low CD4 cell count [Althoff, et al. 2019; Trickey, et al. 2016; Helleberg, et al. 2015].
History of particular comorbidities may also influence medication choice for those starting ART. For example, patients with a history of metabolic disease may wish to avoid protease inhibitors because of the association with central obesity, and patients with risk factors for significant renal disease may wish to avoid tenofovir disoproxil fumarate. If patients do have significant risk for and are taking ART or other medications that can affect these conditions, more frequent monitoring may be warranted [Crum-Cianflone, et al. 2010]. Nonalcoholic steatohepatitis is observed in 30% to 40% of people with HIV [Kaspar and Sterling 2017] and may affect both monitoring and medication choice.
Endocrine conditions, such as metabolic syndrome, insulin resistance, dyslipidemia, lipodystrophy, and osteoporosis, may be worsened by certain antiretroviral medications. A full medication history will help clinicians identify the possibility of ART-associated contribution to these conditions [Noubissi, et al. 2018; Gazzaruso, et al. 2003]. Because thyroid disease and hypogonadism occur more often in people with HIV than in those without, a low threshold for screening for these conditions is appropriate.
Aging: As the population living with HIV ages, frailty, functional, and cognitive assessments are essential. Baseline discussion of memory loss, neuropathic symptoms, and chronic pain can help identify conditions that may affect ART adherence. Nadir CD4 cell count is a predictor of cognitive impairment and disorders [Ellis, et al. 2011]. Collecting structured data through use of standardized assessments will help clinicians to determine illness course; standardized assessment tools include the MoCA Cognitive Assessment, Mini-Cog, and MMSE, as noted above. An annual assessment of functional status is also indicated.
Psychosocial status: Baseline and annual psychosocial assessments, as described in Table 2, below, include a detailed sexual, trauma, substance use, and psychiatric history; more frequent assessment may be required for patients who require follow-up in any area. Care providers, particularly those new to HIV care, may initially feel uncomfortable conducting these assessments. Resources are provided below for structured assessments; a team approach when possible may be helpful and allow for incorporation of multidisciplinary assessments, including those of a case manager and clinical social worker.
Sexual health: Discussion of sexual health, including a patient’s history of STIs, is an important component of the baseline and annual assessments and is an opportunity to discuss a patient’s concerns and questions. The frequency of the sexual health assessment is based on risk factors. It is particularly important to use nonjudgmental, sex-positive language in this discussion to establish a strong connection and facilitate open discussion. Discussion of U=U (undetectable = untransmittable) in the clinical setting can facilitate reduction of stigma and discussion of important considerations in sexual health.
Reproductive status: Clinicians should ascertain reproductive history and goals with all patients and address contraception and plans for conception with patients of childbearing potential. Patients wishing to have children should be supported and provided with information on current strategies to eliminate perinatal HIV transmission. Risk of perinatal transmission is less than 1% when patients are virally suppressed and with informed management of the perinatal period [Ioannidis, et al. 2001]. For patients who are pregnant or planning pregnancy, care providers should discuss appropriate preconception planning, including folate use, medication safety, and plans for breastfeeding, as well as the risk to a partner without HIV if the patient has a detectable viral load. Education about HIV pre-exposure prophylaxis should be provided when indicated.
Menopause, whether natural or surgical, has been associated with increased fatigue and muscle aches or pains in people with HIV [Schnall, et al. 2018].
Guide to the tables below: Although the tables below are comprehensive in scope, this committee supports a flexible approach in using this guide to determine elements that should be included in a comprehensive initial history and physical examination. All aspects of the patient history and physical examination do not have to be covered in a single visit or by the primary care clinician. For some care providers and patients, the best approach may be to spend 2 or more visits completing the initial assessment and address some aspects of the history and physical examination during follow-up visits.
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| Table 1: HIV, Medications, and General Medical Status and History for Adults With HIV
*Frequency Key: I = initial (baseline) visit; A = annual visit; E = every visit |
|
Assessment
|
To Include
|
Frequency*
|
|
I
|
A
|
E
|
|
Current HIV-Specific Status and History
|
| HIV |
| I | | |
| Antiretroviral therapy |
Date of ART initiation Current ART regimen Previous ART regimens and reasons for any changes in regimens History of drug resistance, if known Adverse effects Current adherence status and challenges
| I | A | |
| Viral load |
Most recent viral load Peak viral load
| I | A | |
| CD4 cell count |
| I | A | |
| AIDS-defining conditions |
Previous diagnoses and treatments History of malignancies and treatments Investigation of symptoms such as weight loss, night sweats, or chronic cough
| I | | |
| Opportunistic infections |
Previous OI prophylaxis Previous diagnoses and treatment, including latent TB infection Adverse reactions to medications for OI prophylaxis or treatment
| I | | |
|
Current Medications
|
| Complete medication list |
All medications: prescribed, over-the-counter, herbal preparations; include nonpharmacologic agents Potential drug-drug interactions Adverse effects Challenges with adherence to prescribed medications
| I | A | E |
|
Current General Medical Status and History
|
| Immunizations |
| I | A | |
| Age-related disease screening |
| I | A | |
| Cardiovascular |
History of cardiac events, stroke, and treatment History of hypertension History of diabetes or insulin resistance Risk factors for CVD Family history of CVD
| I | A | |
| Respiratory |
| I | A | |
| Cancer |
History of prior malignancies and treatment Previous age-appropriate screening and results Family history of malignancies
| I | A | |
| Renal |
| I | | |
| Hepatic |
| I | | |
| Endocrine |
Symptoms of thyroid dysfunction or hypogonadism Sexual dysfunction Weight loss or weight gain Family history of metabolic syndrome and thyroid disease History of osteoporosis and treatment, fractures, and previous screening History of lipodystrophy and treatment Use of hormonal therapy (including treatments obtained without prescription) Current and previous ART use, which may contribute to metabolic syndrome, lipodystrophy, and insulin resistance
| I | A | |
| Gastrointestinal |
History of GI disease and treatment GI-related adverse effects of medications and effect (if any) on adherence to prescribed medications Family history of GI disease
| I | A | |
| Vision |
Changes in vision, including blurry vision, double vision, flashes of light, loss of vision, use of glasses, and blindness or legal blindness
| I | A | |
| Hearing |
| I | A | |
| Neurologic |
History of neurocognitive assessment and results Assessment of current neurocognitive status, preferably using standardized tools such as the MoCA Test (requires an account), Mini-Cog, or MMSEHistory of neuropathy and treatment Assessment of symmetric distal polyneuropathy, which is common, particularly in patients exposed to earlier generations of ART
| I | A | |
| Dermatologic |
History of psoriasis and treatment History of seborrheic dermatitis and treatment History of atopic dermatitis and xerosis and treatment History of skin cancer and treatment Note: Dermatitis can worsen with degree and duration of immunosuppression.
| I | A | |
| Surgery |
| I | A | |
| Pain |
| I | | E |
| Sleep |
| I | | |
| Nutrition |
| I | | E |
| Frailty |
| I | A | |
| Travel |
Recent travel; assess for potential exposure to infectious disease Frequency and location of international travel (work or leisure) Status of travel-related immunizations Lifetime travel history, if indicated
| I | A | |
| Pets |
| I | A | |
Abbreviations: ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; GI, gastrointestinal; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; MMSE, Mini-Mental State Examination; NYSDOH AI, New York State Department of Health AIDS Institute; OI, opportunistic infection; TB, tuberculosis; U=U, undetectable = untransmittable; USDA, United States Department of Agriculture; WPATH, World Professional Association for Transgender Health.
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| Table 2: Psychosocial, Behavioral Health, Sexual Health, and Well-Being Assessment of Adults With HIV
*Frequency Key: I = initial (baseline) visit; A = annual visit; N = as needed |
|
Assessment
|
To Include
|
Frequency*
|
|
I
|
A
|
N
|
|
Gender and Sexual Identity
|
| Gender identity |
| I | A | N |
| Current sexual identity |
| I | A | N |
| Gender transition |
Gender transition goals; successes and challenges History of, planned, or desired gender-affirming surgery Current, past, or planned use of gender-affirming hormones Source of gender-affirming hormones Adverse effects of gender-affirming treatments
| I | | |
| Inventory of sexual organs |
Presence or absence of penis, testes, prostate, breasts, vagina, cervix, uterus, and ovaries; determination of patient’s preferred terms for body parts
| I | A | N |
|
Current Psychosocial Status and History
|
| Housing |
| I | A | N |
| Family and other significant relationships and responsibilities |
Immediate and extended family members as defined by the patient Significant relationships HIV disclosure status Financial and care-giving dependents, including children, spouse or life partner, aging parents, and extended or chosen family members Community support, including functional needs and agency or family assistance Transportation Pets in home Monitor for signs of instability.
| I | A | |
| Interpersonal and social support network |
Members of the patient’s primary interpersonal and social support network People to whom the patient has disclosed their HIV status Discussion of experienced and perceived stigma Monitor for signs of instability.
| I | A | N |
| Employment |
Current employment status or employment goals Access to financial support if unemployed or under-employed Employment-associated risks to health or well-being, including stigma and discrimination
| I | A | |
| Medical insurance |
| I | A | N |
| Incarceration |
| I | | |
| End-of-life planning |
| I | A | |
|
Current Mental Health Status and History
|
| Mental illness |
History of mental illness and treatment Adverse reactions to medications History of psychiatric hospitalization Suicide risk assessment and past history of suicide attempts Family history
| I | A | |
| Trauma |
History of trauma, including domestic violence; physical, verbal, sexual, or emotional abuse; or witnessed trauma History or current experience of elder abuse Any effects on current function and coping strategies
| I | A | N |
| Stress |
| I | A | N |
|
Current Substance Use and History
|
| Alcohol |
History of use, including use disorder diagnosis and treatment Adverse reactions to medications If indicated, implementation of a harm reduction treatment plan
| I | A | N |
| Tobacco use and vaping |
| I | A | N |
| Use of nonprescription drugs and misuse of prescribed drugs |
All types of drug use, including misused prescription medications History of use, including use disorder diagnosis and treatment Route of use History of overdose If indicated, implementation of a harm reduction treatment plan
| I | A | N |
|
Sexual and Reproductive Health and History
|
| Sex partner(s) and activity |
Current sex partner(s) HIV, ART, and viral load status of partner(s), if known; PrEP and other measures to prevent STIs used by partner(s) Frequency of and preferred sexual activities; challenges History of sexual dysfunction History of or current engagement in transactional sex
| I | A | N |
| Sexually transmitted infections |
History of and treatment for syphilis, gonorrhea, chlamydia, human papillomavirus, and other STIs Source of prior treatment for any STI Assessment of ongoing risk factors, and if indicated, implementation of harm or risk reduction plan; use of condoms or other barrier protection
| I | A | N |
| Reproductive history |
| I | | |
| Reproductive goals |
| I | | N |
Abbreviations: ADAP, AIDS Drug Assistance Program; ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; C-SSRS, Columbia-Suicide Severity Rating Scale; NYSDOH AI, New York State Department of Health AIDS Institute; PHQ, Patient Health Questionnaire; PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection; U=U, undetectable = untransmittable; USPSTF, U.S. Preventive Services Task Force.