How to do an HIV consult

ID and reason for referral

• Age, gender identity, country of origin, chief complaint, and reason for referral

PMHx

• HIV: date diagnosed, history of opportunistic infections (OIs) (before and after diagnosis), most recent CD4 count and viral load, nadir CD4 if known, and antiretrovirals (ARVs) history (i.e. when started, on which ARVs, reasons for regimen switches (e.g. drug failure vs tolerance concernes). HIV risk factors important to known only insofar as need for ongoing counselling/harm reduction (i.e. from endemic area, serodiscordant partnership, IVDU).
• Infectious history: previous infections including HCV, HBV, and STIs
• Malignancies: types, treatments, dates (may be HIV-related or impact HIV Rx)
• Non-ID related history (DM, HTN, dyslipidemia, renal failure, liver disease can be a result of HIV or can impact HIV Rx choices)

PSHx

• Any surgery involving prosthetic material (vascular grafts, pacemaker, prosthetic valces/joints, VP shunts) with dates and material used

Medication

• Document all current ARVs & doses (use generic rather than trade names --- helps you learn).
• Ascertain ARV adherence --- how many missed doses in past month.
• If severe immunocompromise (i.e. CD4 <250 cell/mm3), are they on Septra +/- aizthromycin prophylaxis for PJP and MAC, respectively? Any other prophylaxis based on prior OIs?
• Start & stop dates of current antimicrobials (previous Abx + dates can be written in the HPI)
• Other Rx, especially immunosuppressives (document all Rx as potential ARV interactions)

Vaccination History

• Routine childhood immunizations + hepatitis A/B, influenza, pneumococcus
• BCG and age received (can affect utility of TB skin test)

Allergies

• Which medications, description of reaction and timing, how long ago. Skin testing done?
• If PCN allergy: have they ever tolerated a cephalosporin or carbapenem previously? (can list names of antibiotics to help patient remember or check the Rx history in EPR/Powerchart)

Social History

• EtOH/recreation drugs/smoking
• Ongoing/recurrent high-risk behaviours, sexual activities, drug use; reinforce safety
• Occupation/drug benefit situation (can affect access to ARVs)
• Sexual orientation (avoid assumptions)
• Is family aware of status and can messages be left for patient on voice mail?
• Assess coping, safety, supports, depression, financial needs (affect health and adherence)
• Immigrant and refugee status when relevant (reasurance re non-reporting if non-status)
• Has partner been notified? Offer supports in doing so if not yet done.

History of Present Illness

• Will depend on whether seeing patient in clinic or in hospital
• In clinic, focus will be on HIV history as in PMHx above, along with a full review of systems:
  • S&S related to HIV/OISs: fevers, chills, sweats, cough, SOB, headaches, CNS symptoms, abdominal pain, diarrhea, rashes, lymph nodes, genital ulcers/discharge
  • S&S related to adverse events due to ARVs: lipoatrophy/dystrophy, abdominal pain/nausea/vomiting/diarrhea, rashes, neuropsychiatric symptoms
  • Any recent hospitalizations/specialist visits (i.e. cardiac events, infectious events)
• In hospital, see "how to do an ID consult" for more details. Consider OIs or medication adverse events as cause for presentation
• If febrile (in/outpatient), make sure you take a travel history for the last 3 months at least
• Discuss family planning and pregnancy desires if relevant

Physical Exam

• Full vital signs (Tmax if in hospital)
• General exam for lipodystrophy, cachexia
• Oral cavity for thrush, oral hairy leukoplakia, KS, HSV, aphthous ulcers, fundoscopy
• Lymph node and dermatological exam (various rashes seen in HIV, Kaposi's sarcoma)
• Genitalia for warts, ulcers, discharge
• Complete CNS examination on first outpatient visit then as per symptoms

Investigations

• General: CBC, lytes, Cr, LFTs, CK, amylase, LDH, lipid profile, glucose, CXR, UA, G6PD, ßhCG
• HIV-specific:
  • Make sure you see a documented HIV test. If not in chart, call PHL to fax over.
  • Current CD4 count, viral load (important to know CD4 nadir & response to Rx)
  • Genotyping
  • HLA B*5701 for abacavir hypersensitivity, +/- tropism if maraviroc to be used
• Other infections:
  • Hep A/B/C serology (anti-HAV IgG, HBsAG, HBsAb, HBcAb, anti-HCV), syphilis serology, toxoplasma IgG & cryptococcal Ag if severely immunocompromised, TB skin test, urine gonococcal/Chlamydia PCR
  • PAP smear +/- rectal/anoscopy
  • Micro based on reason for referral (see "How to do an ID consult")
• Public Health: for samples sent to PHL, you can call their phone service: 416-235-5755.
• Imaging: look at the images, not just reports. Call the radiologist directly to review if specific question not addressed in report or if further information required.

Impression & Plan

• Summarize duration of HIV, whether or ARVs and for how long and degree of response (CD4 count and viral load)
• Address stability of HIV and current state of immunocompromise --- do they need prophylaxis of any kind? Changes to their ARVs based on virologic failure?
• Address adverse events and need to change ARVs or manage complications (i.e. lipids, HTN, weight gain)
• Determine plan for presenting complaint/concerns in clinic, if any (i.e. further investigations vs. medication addition/change vs. referral).