[Table, General Medical Status, History, and Physical Examination]. - Comprehensive Primary Care for Adults With HIV

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	History of HIV testing Date and source of diagnosis Route of exposure, if known HIV type; if unknown, see NYSDOH AI guideline Diagnosis and Management of HIV-2 in Adults	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 Knowledge of U=U If ART has not been initiated, see NYSDOH AI guideline Rapid ART Initiation.	I	A
Viral load	Most recent viral load Peak viral load	I	A
CD4 cell count	Most recent CD4 cell count Nadir 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	History of immunizations Status of HIV- and age-related preventive immunizations	I	A
Age-related disease screening	Results of previous age-related disease screening tests	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	History of COPD and treatment Current tobacco/vape use and smoking history	I	A
Cancer	History of prior malignancies and treatment Previous age-appropriate screening and results Family history of malignancies	I	A
Renal	History of renal disease and treatment Consider ART history Consider associated comorbidities	I
Hepatic	History of and treatment for viral hepatitis (HAV, HBV, or HCV) Adverse reactions to medications Risk factors for nonalcoholic steatohepatitis Past alcohol use Current alcohol use	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	Changes in hearing Recent audiology testing or new hearing aid use	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 MMSE History 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	History of surgical procedures, including adverse reactions to anesthesia History of or planned gender-affirming surgery (see WPATH Standards of Care Version 8)	I	A
Pain	History of evaluation and treatment for chronic pain (initial visit) Current treatment for chronic pain (every visit) See CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022	I		E
Sleep	History of chronic obstructive sleep apnea and treatment History of sleep disturbances and treatment	I
Nutrition	History of wasting Dietary habits, including appetite Food insecurity Note: If indicated, see USDA Food Security Survey Tools	I		E
Frailty	Functional status History of gait instability or other problems associated with frailty Assessment of current status using standardized tools, such as those available through the Comprehensive Geriatric Assessment Toolkit Plus	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	Current and past pet ownership, including exotic animals History of zoonotic diseases and treatment	I	A

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*

Current HIV-Specific Status and History

HIV

History of HIV testing
Date and source of diagnosis
Route of exposure, if known
HIV type; if unknown, see NYSDOH AI guideline Diagnosis and Management of HIV-2 in Adults

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
Knowledge of U=U
If ART has not been initiated, see NYSDOH AI guideline Rapid ART Initiation.

Viral load

Most recent viral load
Peak viral load

CD4 cell count

Most recent CD4 cell count
Nadir CD4 cell count

AIDS-defining conditions

Previous diagnoses and treatments
History of malignancies and treatments
Investigation of symptoms such as weight loss, night sweats, or chronic cough

Opportunistic infections

Previous OI prophylaxis
Previous diagnoses and treatment, including latent TB infection
Adverse reactions to medications for OI prophylaxis or treatment

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

Current General Medical Status and History

Immunizations

History of immunizations
Status of HIV- and age-related preventive immunizations

Age-related disease screening

Results of previous age-related disease screening tests

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

Respiratory

History of COPD and treatment
Current tobacco/vape use and smoking history

Cancer

History of prior malignancies and treatment
Previous age-appropriate screening and results
Family history of malignancies

Renal

History of renal disease and treatment
Consider ART history
Consider associated comorbidities

Hepatic

History of and treatment for viral hepatitis (HAV, HBV, or HCV)
Adverse reactions to medications
Risk factors for nonalcoholic steatohepatitis
Past alcohol use
Current alcohol use

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

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

Vision

Changes in vision, including blurry vision, double vision, flashes of light, loss of vision, use of glasses, and blindness or legal blindness

Hearing

Changes in hearing
Recent audiology testing or new hearing aid use

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 MMSE
History of neuropathy and treatment
Assessment of symmetric distal polyneuropathy, which is common, particularly in patients exposed to earlier generations of ART

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.

Surgery

History of surgical procedures, including adverse reactions to anesthesia
History of or planned gender-affirming surgery (see WPATH Standards of Care Version 8)

Pain

History of evaluation and treatment for chronic pain (initial visit)
Current treatment for chronic pain (every visit)
See CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022

Sleep

History of chronic obstructive sleep apnea and treatment
History of sleep disturbances and treatment

Nutrition

History of wasting
Dietary habits, including appetite
Food insecurity
Note: If indicated, see USDA Food Security Survey Tools

Frailty

Functional status
History of gait instability or other problems associated with frailty
Assessment of current status using standardized tools, such as those available through the Comprehensive Geriatric Assessment Toolkit Plus

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

Pets

Current and past pet ownership, including exotic animals
History of zoonotic diseases and treatment

From: Comprehensive Primary Care for Adults With HIV

Cover of Comprehensive Primary Care for Adults With HIV

Comprehensive Primary Care for Adults With HIV [Internet].

Dyer M, Kerr C, Fine SM, et al.

Baltimore (MD): Johns Hopkins University; 2022 Dec.

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